MEDICARE: BLUE RIDGE LASER EYE ASSOCIATES, P.A.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist
2	207W00000X	Ophthalmology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DF8060	OTHER		RAILROAD MEDICARE
2	2333605	OTHER	NC	MEDICARE GROUP
3	8597	OTHER	SC	MEDICARE GROUP

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	012RE	OTHER	NC	BC/BS OF NORTH CAROLINA

NPI Number	:	1215981428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE LASER EYE ASSOCIATES, P.A.

Provider Business Mailing Address
First Line	:	192 HOSPITAL DR
Second Line	:
City	:	COLUMBUS
State	:	NC
Zip	:	28722-6418
Country	:	US
Telephone Number	:	828-894-3037
Fax Number	:	828-894-7041

Provider Business Practice Location Address
First Line	:	192 HOSPITAL DR
Second Line	:
City	:	COLUMBUS
State	:	NC
Zip	:	28722-6418
Country	:	US
Telephone Number	:	828-894-3037
Fax Number	:	828-894-7041

Authorized Official
Title or Position	:	BILLING ADMINISTRATOR
Name	:	MS. GENEVA F NELON
Credential	:
Telephone Number	:	828-894-3037

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	11/09/2007

192 HOSPITAL DR
COLUMBUS, NC
28722-6418

Practice Phone: 828-894-3037
Practice Fax: 828-894-7041