Provider Demographics
NPI:1881687689
Name:BLUE RIDGE RADIOLOGY, P.C.
Entity Type:Organization
Organization Name:BLUE RIDGE RADIOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-573-9062
Mailing Address - Street 1:3053 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1720
Mailing Address - Country:US
Mailing Address - Phone:423-968-1144
Mailing Address - Fax:423-968-3453
Practice Address - Street 1:3053 W STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1720
Practice Address - Country:US
Practice Address - Phone:423-968-1144
Practice Address - Fax:423-968-3453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA242032OtherANTHEM
CD5029OtherPGBA (RR MEDICARE)
1521046OtherUMWA
373437500OtherDOL
023464700OtherBLACK LUNG
=========003OtherCHAMPUS
1521046OtherUMWA