=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245486067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2008
-----------------------------------------------------
Last Update Date | 03/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2209 S STERLING ST SUITE 400
-----------------------------------------------------
City | MORGANTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28655-4091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-580-4661
-----------------------------------------------------
Fax | 828-580-4698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2209 S STERLING ST SUITE 400
-----------------------------------------------------
City | MORGANTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28655-4091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-580-4661
-----------------------------------------------------
Fax | 828-580-4698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP-CFO
-----------------------------------------------------
Name | PATRICIA MOLL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-580-5003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0000X
-----------------------------------------------------
Taxonomy Name | Obstetrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VX0201X
-----------------------------------------------------
Taxonomy Name | Gynecologic Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207VM0101X
-----------------------------------------------------
Taxonomy Name | Maternal & Fetal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207VE0102X
-----------------------------------------------------
Taxonomy Name | Reproductive Endocrinology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------