1467672204 NPI number — BLUE RIDGE NEPHROLOGY, P.A.

Table of content: (NPI 1467672204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467672204 NPI number — BLUE RIDGE NEPHROLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE NEPHROLOGY, P.A.
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:
BLUE RIDGE NEPHROLOGY AND HYPERTENSION CENTER
Provider Other Organization Name Type Code:
5
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:
1467672204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 SHADOWLINE DR STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28607-5022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-263-8707
Provider Business Mailing Address Fax Number:
828-263-8710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 SHADOWLINE DR STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28607-5022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-263-8707
Provider Business Practice Location Address Fax Number:
828-263-8710
Provider Enumeration Date:
04/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CASALE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRACTICE AMDINISTRATOR-MANAGER
Authorized Official Telephone Number:
828-263-8707

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  28557 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1083615058 . This is a "NEPHROLOGY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386962918 . This is a "NEPHROLOGY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5908642 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".