Provider Demographics
NPI:1720318009
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP-CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-580-5003
Mailing Address - Street 1:730 MALCOLM BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CONNELLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28612-8079
Mailing Address - Country:US
Mailing Address - Phone:828-580-7962
Mailing Address - Fax:828-580-3392
Practice Address - Street 1:730 MALCOLM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612-8079
Practice Address - Country:US
Practice Address - Phone:828-580-7962
Practice Address - Fax:828-580-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1227YOtherBCBS
NC891227YMedicaid