Basic Information
| Provider Information | |||||||||
| NPI: | 1194746289 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE UROLOGICAL ASSOC., PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 MEDICAL CENTER CIR | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 03/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUCKLEY | ||||||||
| AuthorizedOfficialFirstName: | CARIE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5403453556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0101033256 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 049990 | 01 | VA | ANTHEM | OTHER | 279040 | 01 | VI | ANTHEM | OTHER | 011346 | 01 | VA | ANTHEM | OTHER | 011345 | 01 | VA | ANTHEM | OTHER | 440822 | 01 | VA | ANTHEM | OTHER |