Provider Demographics
NPI:1316054802
Name:BLUE RIDGE ENT & FACIAL SURGERY CENTER, INC.
Entity type:Organization
Organization Name:BLUE RIDGE ENT & FACIAL SURGERY CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MARCH
Authorized Official - Last Name:JONES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:304-324-2954
Mailing Address - Street 1:510 CHERRY ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-3338
Mailing Address - Country:US
Mailing Address - Phone:304-324-2954
Mailing Address - Fax:304-324-2955
Practice Address - Street 1:510 CHERRY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3338
Practice Address - Country:US
Practice Address - Phone:304-324-2954
Practice Address - Fax:304-324-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9294501Medicare ID - Type Unspecified