Healthcare Provider Details

I. General information

NPI: 1821083551
Provider Name (Legal Business Name): BLUE RIDGE DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 HOSPITAL DR
CLYDE NC
28721-8027
US

IV. Provider business mailing address

540 HOSPITAL DR
CLYDE NC
28721-8027
US

V. Phone/Fax

Practice location:
  • Phone: 828-456-7343
  • Fax: 828-452-0939
Mailing address:
  • Phone: 828-456-7343
  • Fax: 828-452-0939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JASON MASTERS
Title or Position: PRESIDENT TREASURER
Credential: MD
Phone: 828-456-7343