Provider Demographics
NPI:1942389838
Name:BLUE RIDGE PEDIATRICS LLP
Entity Type:Organization
Organization Name:BLUE RIDGE PEDIATRICS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DAVANZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-782-0021
Mailing Address - Street 1:3124 BLUE RIDGE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612
Mailing Address - Country:US
Mailing Address - Phone:919-782-0021
Mailing Address - Fax:919-571-0825
Practice Address - Street 1:3124 BLUE RIDGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612
Practice Address - Country:US
Practice Address - Phone:919-782-0021
Practice Address - Fax:919-571-0825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty