Provider Demographics
NPI:1114038163
Name:BLUE RIDGE PEDIATRIC & ADOLESCENT MEDICINE, INC
Entity Type:Organization
Organization Name:BLUE RIDGE PEDIATRIC & ADOLESCENT MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-262-0100
Mailing Address - Street 1:579 GREENWAY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4809
Mailing Address - Country:US
Mailing Address - Phone:828-262-0100
Mailing Address - Fax:828-264-7592
Practice Address - Street 1:579 GREENWAY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4809
Practice Address - Country:US
Practice Address - Phone:828-262-0100
Practice Address - Fax:828-264-7592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39798208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0110KOtherBLUE CROSS BLUE SHIELD
NC890110KMedicaid