1245486067 NPI number — BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.

Table of content: (NPI 1245486067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245486067 NPI number — BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WOMEN'S HEALTHGROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245486067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2209 S STERLING ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
MORGANTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28655-4091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-580-4661
Provider Business Mailing Address Fax Number:
828-580-4698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2209 S STERLING ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
MORGANTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28655-4091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-580-4661
Provider Business Practice Location Address Fax Number:
828-580-4698
Provider Enumeration Date:
08/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FRITTS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
G
Authorized Official Title or Position:
SVP/CFO
Authorized Official Telephone Number:
828-580-4661

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207VE0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 121106 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 9800595 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 55709 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 39990 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 35513 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5950522 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200400734 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 23421 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 100615 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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