MEDICARE: BLUE RIDGE HEARING GROUP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332S00000X	Hearing Aid Equipment	2101001696	VA

General Provider Information

NPI Number	:	1417355090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE HEARING GROUP

Provider Business Mailing Address
First Line	:	12925 BOOKER T WASHINGTON HWY
Second Line	:	STE.202
City	:	HARDY
State	:	VA
Zip	:	24101-3971
Country	:	US
Telephone Number	:	540-444-5659
Fax Number	:	540-301-1167

Provider Business Practice Location Address
First Line	:	12925 BOOKER T WASHINGTON HWY
Second Line	:	STE.202
City	:	HARDY
State	:	VA
Zip	:	24101-3971
Country	:	US
Telephone Number	:	540-444-5659
Fax Number	:	540-301-1167

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. GREGORY TODD HARVEY
Credential	:	DMD
Telephone Number	:	540-444-5659

Provider Enumeration Date	:	12/12/2014
Last Update Date	:	12/12/2014

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