Basic Information
| Provider Information | |||||||||
| NPI: | 1730112475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE FOOT AND ANKLE CLINIC PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 887A RIO EAST CT | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229018004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349798116 | ||||||||
| FaxNumber: | 4349798880 | ||||||||
| Practice Location | |||||||||
| Address1: | 887A RIO EAST CT | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229018004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349798116 | ||||||||
| FaxNumber: | 4349798880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | MURRAY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4349798116 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 0103000815 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 0103300932 | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 010136016 | 05 | VA | MEDICAID | 010135770 | 05 | VA | MEDICAID | 010151503 | 05 | VA | MEDICAID | 010193133 | 05 | VA | MEDICAID |