Provider Demographics
NPI:1922244938
Name:BLACKSBURG INTERNAL MEDICINE AND CARDIOLOGY
Entity Type:Organization
Organization Name:BLACKSBURG INTERNAL MEDICINE AND CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-953-0530
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24063-0928
Mailing Address - Country:US
Mailing Address - Phone:540-953-0530
Mailing Address - Fax:540-953-0510
Practice Address - Street 1:840 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7023
Practice Address - Country:US
Practice Address - Phone:540-953-0530
Practice Address - Fax:540-953-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047913261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101047913OtherVIRGINIA MEDICAL LICENSE
BW3156711OtherDEA
BW3156711OtherDEA