Healthcare Provider Details

I. General information

NPI: 1194780411
Provider Name (Legal Business Name): BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 SUGAR HILL RD
MARION NC
28752-5565
US

IV. Provider business mailing address

1860 SUGAR HILL RD
MARION NC
28752-5565
US

V. Phone/Fax

Practice location:
  • Phone: 828-652-8727
  • Fax: 828-652-8793
Mailing address:
  • Phone: 828-652-8727
  • Fax: 828-652-8793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40576
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40576
License Number StateNC

VIII. Authorized Official

Name: MR. ROBERT FRITTS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 828-580-5000