Provider Demographics
NPI:1932504446
Name:MOUNTAIN RIDGE PEDIATRICS
Entity Type:Organization
Organization Name:MOUNTAIN RIDGE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-560-4676
Mailing Address - Street 1:2054 PRO POINTE LN
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-8021
Mailing Address - Country:US
Mailing Address - Phone:540-560-4676
Mailing Address - Fax:
Practice Address - Street 1:2054 PRO POINTE LN
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-8021
Practice Address - Country:US
Practice Address - Phone:540-560-4676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242820261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care