Provider Demographics
NPI:1407203052
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:BLUE RIDGE GERIATRICS
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:828-580-6554
Mailing Address - Street 1:2209 S STERLING ST STE 330
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-4093
Mailing Address - Country:US
Mailing Address - Phone:828-580-5706
Mailing Address - Fax:828-580-8033
Practice Address - Street 1:2209 S STERLING ST STE 330
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4093
Practice Address - Country:US
Practice Address - Phone:828-580-5706
Practice Address - Fax:828-580-8033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2327875OtherMEDICARE GROUP PTAN