1982889788 NPI number — BLUE RIDGE SURGICAL, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982889788 NPI number — BLUE RIDGE SURGICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE SURGICAL, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982889788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2855 OLD HIGHWAY 5
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
BLUE RIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30513-6248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-632-5947
Provider Business Mailing Address Fax Number:
706-632-5950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2855 OLD HIGHWAY 5
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
BLUE RIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30513-6248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-632-5947
Provider Business Practice Location Address Fax Number:
706-632-5950
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITAKER
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
SEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-632-5947

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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