Provider Demographics
NPI:1578842035
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:BLUE RIDGE RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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 1:2134 14TH AVENUE CIR NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-7357
Mailing Address - Country:US
Mailing Address - Phone:828-580-1235
Mailing Address - Fax:828-433-1992
Practice Address - Street 1:2134 14TH AVENUE CIR NW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-7357
Practice Address - Country:US
Practice Address - Phone:828-580-1235
Practice Address - Fax:828-433-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC026KPOtherBCBS
NC5920098Medicaid
NC5920098Medicaid