Provider Demographics
NPI:1912092867
Name:BLUE RIDGE WOMEN'S CENTER, PA
Entity Type:Organization
Organization Name:BLUE RIDGE WOMEN'S CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:VENUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-835-5945
Mailing Address - Street 1:150 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2430
Mailing Address - Country:US
Mailing Address - Phone:336-835-5945
Mailing Address - Fax:336-835-5974
Practice Address - Street 1:150 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2430
Practice Address - Country:US
Practice Address - Phone:336-835-5945
Practice Address - Fax:336-835-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400614207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7260595OtherAETNA
NC015YWOtherBC/BS OF NC
NCA9945OtherMEDCOST
NC89015YWMedicaid
NC2338976Medicare ID - Type UnspecifiedMEDICARE