1932539095 NPI number — BLUE RIDGE MEDICAL GROUP, INC

Table of content: (NPI 1932539095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932539095 NPI number — BLUE RIDGE MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE 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:
GASTROENTEROLOGY SPECIALISTS, 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:
1932539095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 MICA AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MORGANTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28655-8135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-437-7702
Provider Business Mailing Address Fax Number:
828-437-7041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 MALCOLM BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONNELLY SPRINGS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28612-7918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-437-7702
Provider Business Practice Location Address Fax Number:
828-437-7041
Provider Enumeration Date:
11/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FRITTS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
G
Authorized Official Title or Position:
CORPORATE OFFICER
Authorized Official Telephone Number:
828-580-4220

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  2010-01029 , 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)





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