Basic Information
| Provider Information | |||||||||
| NPI: | 1285687566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE ANES & PAIN SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7096 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
| FaxNumber: | 2099567733 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SUNSET LANE | ||||||||
| Address2: | |||||||||
| City: | CULPEPER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408294100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | WILCOX | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5408294100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 227234 | 01 | VA | ANTHEM BCBS | OTHER | CK5313 | 01 | VA | RAILROAD MEDICARE | OTHER |