=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740558949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2011
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 MALCOLM BOULEVARD
-----------------------------------------------------
City | CONNELLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28612-8615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-580-3555
-----------------------------------------------------
Fax | 828-874-2111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 845 MALCOLM BOULEVARD
-----------------------------------------------------
City | CONNELLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28612-8615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-580-3555
-----------------------------------------------------
Fax | 828-874-2111
-----------------------------------------------------
=====================================================
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 | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 969601640
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------