Healthcare Provider Details

I. General information

NPI: 1770545550
Provider Name (Legal Business Name): BLUE RIDGE DERMATOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 MACON POND RD STE 300
RALEIGH NC
27607-6320
US

IV. Provider business mailing address

4225 MACON POND RD STE 300
RALEIGH NC
27607-6320
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-1050
  • Fax: 919-510-5090
Mailing address:
  • Phone: 919-781-1050
  • Fax: 919-510-5090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LYNDA A AMSDEN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 919-781-1050