Basic Information
| Provider Information | |||||||||
| NPI: | 1114937109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACKSBURG NEUROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2955 MARKET ST STE B | ||||||||
| Address2: | |||||||||
| City: | CHRISTIANSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240736575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403816211 | ||||||||
| FaxNumber: | 5406456623 | ||||||||
| Practice Location | |||||||||
| Address1: | 2955 MARKET ST STE B | ||||||||
| Address2: | |||||||||
| City: | CHRISTIANSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240736575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403816211 | ||||||||
| FaxNumber: | 5403819483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | CRAMER | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5403816211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101237795 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.