Healthcare Provider Details

I. General information

NPI: 1154571081
Provider Name (Legal Business Name): BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 02/14/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 MALCOLM BLVD.
CONNELLY SPRINGS NC
28612
US

IV. Provider business mailing address

722 MALCOLM BLVD.
CONNELLY SPRINGS NC
28612
US

V. Phone/Fax

Practice location:
  • Phone: 828-580-7655
  • Fax: 828-874-2278
Mailing address:
  • Phone: 828-580-7655
  • Fax: 828-874-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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