=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598941304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2008
-----------------------------------------------------
Last Update Date | 02/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 MALCOLM BLVD
-----------------------------------------------------
City | VALDESE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28690-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-874-3160
-----------------------------------------------------
Fax | 828-874-2820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 700
-----------------------------------------------------
City | VALDESE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28690-0700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-874-3160
-----------------------------------------------------
Fax | 828-874-2820
-----------------------------------------------------
=====================================================
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 | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 15193
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------