Provider Demographics
NPI:1467672204
Name:BLUE RIDGE NEPHROLOGY, P.A.
Entity Type:Organization
Organization Name:BLUE RIDGE NEPHROLOGY, P.A.
Other - Org Name:BLUE RIDGE NEPHROLOGY AND HYPERTENSION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE AMDINISTRATOR-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:CASALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-263-8707
Mailing Address - Street 1:400 SHADOWLINE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5022
Mailing Address - Country:US
Mailing Address - Phone:828-263-8707
Mailing Address - Fax:828-263-8710
Practice Address - Street 1:400 SHADOWLINE DR STE 203
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5022
Practice Address - Country:US
Practice Address - Phone:828-263-8707
Practice Address - Fax:828-263-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28557174400000X
207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083615058OtherNEPHROLOGY
1386962918OtherNEPHROLOGY
NC5908642Medicaid
NC2348830Medicare PIN