Provider Demographics
NPI:1922064872
Name:BLUE RIDGE ORTHOPAEDICS AND SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:BLUE RIDGE ORTHOPAEDICS AND SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:REFVEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-719-0011
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-0472
Mailing Address - Country:US
Mailing Address - Phone:336-719-0011
Mailing Address - Fax:336-719-0381
Practice Address - Street 1:708 S SOUTH ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4426
Practice Address - Country:US
Practice Address - Phone:336-719-0011
Practice Address - Fax:336-719-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600298207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012NMMedicaid
NC2308056Medicare ID - Type UnspecifiedGROUP NUMBER FOR MEDICARE
NC4251900001Medicare NSC