Healthcare Provider Details

I. General information

NPI: 1699197012
Provider Name (Legal Business Name): BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 MALCOLM BLVD SUITE 200
CONNELLY SPRINGS NC
28612-7920
US

IV. Provider business mailing address

720 MALCOLM BLVD SUITE 200
CONNELLY SPRINGS NC
28612-7920
US

V. Phone/Fax

Practice location:
  • Phone: 828-580-7536
  • Fax: 828-580-7537
Mailing address:
  • Phone: 828-580-7536
  • Fax: 828-580-7537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2009-00695
License Number StateNC

VIII. Authorized Official

Name: PATRICIA MOLL
Title or Position: SVP-CFO
Credential:
Phone: 828-580-5003