Healthcare Provider Details

I. General information

NPI: 1093811168
Provider Name (Legal Business Name): BLUE RIDGE GYNECOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PEYTON ST
WINCHESTER VA
22601-3935
US

IV. Provider business mailing address

130 PEYTON ST
WINCHESTER VA
22601-3935
US

V. Phone/Fax

Practice location:
  • Phone: 540-678-1433
  • Fax: 540-678-1719
Mailing address:
  • Phone: 540-678-1433
  • Fax: 540-678-1719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN E. WADE
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 540-678-1433