1194780411 NPI number — BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC

Table of content: (NPI 1194780411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194780411 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:
MCDOWELL MEDICAL ASSOCIATES, PA
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:
1194780411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1860 SUGAR HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28752-5565
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-652-8727
Provider Business Mailing Address Fax Number:
828-652-8793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1860 SUGAR HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28752-5565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-652-8727
Provider Business Practice Location Address Fax Number:
828-652-8793
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRITTS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
828-580-5000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  40576 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 40576 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 690168L , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 023T1 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 34D0699936 . This is a "CLIA #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5915267 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34D0947561 . This is a "CLIA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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