Provider Demographics
NPI:1164775342
Name:BLUE RIDGE MEDICAL CENTER
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:607-237-1209
Mailing Address - Street 1:433 CHURCH ST
Mailing Address - Street 2:P.O. BOX 602
Mailing Address - City:NEW MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18834-6603
Mailing Address - Country:US
Mailing Address - Phone:570-465-4500
Mailing Address - Fax:570-465-4501
Practice Address - Street 1:433 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18834-6603
Practice Address - Country:US
Practice Address - Phone:570-465-4500
Practice Address - Fax:570-465-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABM2828929213E00000X
PASP009050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty