Provider Demographics
NPI:1396017752
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:BLUE RIDGE MULTI SPECIALTY CLINIC - MARION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP-CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:FRITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-580-5545
Mailing Address - Street 1:2293 SUGAR HILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-7787
Mailing Address - Country:US
Mailing Address - Phone:828-559-2016
Mailing Address - Fax:
Practice Address - Street 1:2293 SUGAR HILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-7787
Practice Address - Country:US
Practice Address - Phone:828-559-2016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-01186207RC0200X, 207RP1001X
ND2012-00598207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920075Medicaid
NC026JTOtherBLUE CROSS BLUE SHIELD