=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518304955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE HEALTHCARE PARTNERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2013
-----------------------------------------------------
Last Update Date | 05/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 602 BRANDON AVE SUITE 222
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-774-0000
-----------------------------------------------------
Fax | 540-774-0085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2022
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27216-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-222-9299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER MANAGER
-----------------------------------------------------
Name | JOHN JACOB GILLIAM JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-516-7084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------