Provider Demographics
NPI:1528223633
Name:BLUE RIDGE MOUNTAIN INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:BLUE RIDGE MOUNTAIN INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OVNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-635-7231
Mailing Address - Street 1:17 BARCLAY ST
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-3309
Mailing Address - Country:US
Mailing Address - Phone:706-635-7231
Mailing Address - Fax:706-635-7232
Practice Address - Street 1:17 BARCLAY ST
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-3309
Practice Address - Country:US
Practice Address - Phone:706-635-7231
Practice Address - Fax:706-635-7232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00242141AMedicaid
GA00242141AMedicaid
GA254925982BMedicare PIN