Provider Demographics
NPI:1952390221
Name:BLUE RIDGE PODIATRY ASSOCIATES
Entity Type:Organization
Organization Name:BLUE RIDGE PODIATRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:540-885-8891
Mailing Address - Street 1:PO BOX 4205
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-4205
Mailing Address - Country:US
Mailing Address - Phone:336-623-4545
Mailing Address - Fax:206-333-1892
Practice Address - Street 1:390 S MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1767
Practice Address - Country:US
Practice Address - Phone:540-483-7933
Practice Address - Fax:540-463-9454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000391213E00000X
VA0103000371213E00000X
VA0103300877213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009301283Medicaid
VA009301208Medicaid
VA0518620002OtherNSC LEXINGTON LOCATION
VA0518620001OtherNSC STAUNTON LOCATION
VACM9184OtherRR MEDICARE GROUP
VA009301747Medicaid
VA0518620003Medicare NSC
VA009301208Medicaid
VA009301283Medicaid
VAU90597Medicare UPIN
VAC01936Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
VA480000127Medicare ID - Type Unspecified
VA480000126Medicare ID - Type Unspecified
VAT21453Medicare UPIN