1629089776 NPI number — BLUE RIDGE REGIONAL HOSPITAL, INC

Table of content: (NPI 1629089776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629089776 NPI number — BLUE RIDGE REGIONAL HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE REGIONAL HOSPITAL, 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:
MISSION COMMUNITY PRIMARY CARE
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:
1629089776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602373
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-2373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-213-1500
Provider Business Mailing Address Fax Number:
828-651-6570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11728 S 226 HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRUCE PINE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28777-8954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-765-5672
Provider Business Practice Location Address Fax Number:
828-765-5676
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
CLINT
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL DIRECTOR
Authorized Official Telephone Number:
828-659-5196

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , 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: 343426 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 018NU . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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