Provider Demographics
NPI:1194746289
Name:BLUE RIDGE UROLOGICAL ASSOC., PC
Entity type:Organization
Organization Name:BLUE RIDGE UROLOGICAL ASSOC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:540-345-3556
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:70 MEDICAL CENTER CIR
Practice Address - Street 2:SUITE 208
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2273
Practice Address - Country:US
Practice Address - Phone:540-345-3556
Practice Address - Fax:540-342-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033256208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA049990OtherANTHEM
VI279040OtherANTHEM
VA011346OtherANTHEM
VA011345OtherANTHEM
VA440822OtherANTHEM
VAC01112Medicare PIN
VA011345OtherANTHEM