1821083551 NPI number — BLUE RIDGE DERMATOLOGY PA

Table of content: (NPI 1821083551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821083551 NPI number — BLUE RIDGE DERMATOLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE DERMATOLOGY PA
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:
Provider Other Organization Name Type Code:
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:
1821083551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLYDE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28721-8027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-456-7343
Provider Business Mailing Address Fax Number:
828-452-0939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLYDE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28721-8027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-456-7343
Provider Business Practice Location Address Fax Number:
828-452-0939
Provider Enumeration Date:
09/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MASTERS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
JASON
Authorized Official Title or Position:
PRESIDENT TREASURER
Authorized Official Telephone Number:
828-456-7343

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0122K . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 890122K , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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