1902069693 NPI number — BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.

Table of content: (NPI 1902069693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902069693 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:
BLUE RIDGE DIGESTIVE HEALTH
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:
1902069693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2010
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 200
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:
828-580-6752
Provider Business Mailing Address Fax Number:
828-580-6754

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 200
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:
828-580-6752
Provider Business Practice Location Address Fax Number:
828-580-6754
Provider Enumeration Date:
07/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FRITTS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP-CFA
Authorized Official Telephone Number:
82858065545

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  200800387 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5950509 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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