Healthcare Provider Details

I. General information

NPI: 1679387427
Provider Name (Legal Business Name): BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4132 HICKORY BLVD
GRANITE FALLS NC
28630-8371
US

IV. Provider business mailing address

5221 PARAMOUNT PKWY STE 420
MORRISVILLE NC
27560-5491
US

V. Phone/Fax

Practice location:
  • Phone: 828-396-3168
  • Fax: 828-396-8783
Mailing address:
  • Phone: 984-974-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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