Provider Demographics
NPI:1316985070
Name:INTERNAL MEDICINE OF BLACKSBURG LLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE OF BLACKSBURG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-650-2907
Mailing Address - Street 1:3698 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7015
Mailing Address - Country:US
Mailing Address - Phone:540-951-6070
Mailing Address - Fax:540-951-6071
Practice Address - Street 1:3698 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7015
Practice Address - Country:US
Practice Address - Phone:540-951-6070
Practice Address - Fax:540-951-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316985070Medicaid
DF5833OtherRR MEDICARE
DF5833OtherRR MEDICARE
VAC10048Medicare PIN