Healthcare Provider Details

I. General information

NPI: 1588609366
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 E RUTHERFORD ST
LANDRUM SC
29356-1416
US

IV. Provider business mailing address

1504 E RUTHERFORD ST
LANDRUM SC
29356-1416
US

V. Phone/Fax

Practice location:
  • Phone: 864-457-4500
  • Fax: 864-457-2195
Mailing address:
  • Phone: 864-457-4500
  • Fax: 864-457-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12702
License Number StateSC

VIII. Authorized Official

Name: DR. THOMAS IRWIN DASHIELL JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 864-457-4500