Healthcare Provider Details

I. General information

NPI: 1740558949
Provider Name (Legal Business Name): BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 MALCOLM BOULEVARD
CONNELLY SPRINGS NC
28612-8615
US

IV. Provider business mailing address

845 MALCOLM BOULEVARD
CONNELLY SPRINGS NC
28612-8615
US

V. Phone/Fax

Practice location:
  • Phone: 828-580-3555
  • Fax: 828-874-2111
Mailing address:
  • Phone: 828-580-3555
  • Fax: 828-874-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number969601640
License Number StateNC

VIII. Authorized Official

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