MEDICARE: BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC

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	207RH0000X	Hematology (Internal Medicine) Physician	2009-00695	NC

General Provider Information

NPI Number	:	1699197012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	720 MALCOLM BLVD
Second Line	:	SUITE 200
City	:	CONNELLY SPRINGS
State	:	NC
Zip	:	28612-7920
Country	:	US
Telephone Number	:	828-580-7536
Fax Number	:	828-580-7537

Provider Business Practice Location Address
First Line	:	720 MALCOLM BLVD
Second Line	:	SUITE 200
City	:	CONNELLY SPRINGS
State	:	NC
Zip	:	28612-7920
Country	:	US
Telephone Number	:	828-580-7536
Fax Number	:	828-580-7537

Authorized Official
Title or Position	:	SVP-CFO
Name	:	PATRICIA MOLL
Credential	:
Telephone Number	:	828-580-5003

Provider Enumeration Date	:	01/21/2014
Last Update Date	:	03/14/2025

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