Provider Demographics
NPI:1285729178
Name:BLUE RIDGE INTERNAL MEDICINE INC.
Entity type:Organization
Organization Name:BLUE RIDGE INTERNAL MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-487-0232
Mailing Address - Street 1:PO BOX 5065
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-5065
Mailing Address - Country:US
Mailing Address - Phone:304-487-0232
Mailing Address - Fax:304-487-0285
Practice Address - Street 1:407 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2300
Practice Address - Country:US
Practice Address - Phone:304-487-0232
Practice Address - Fax:304-487-0285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003706Medicaid
WV9325201Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER