Provider Demographics
NPI:1588609366
Name:BLUE RIDGE MEDICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:BLUE RIDGE MEDICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:IRWIN
Authorized Official - Last Name:DASHIELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:864-457-4500
Mailing Address - Street 1:1504 E RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:LANDRUM
Mailing Address - State:SC
Mailing Address - Zip Code:29356-1416
Mailing Address - Country:US
Mailing Address - Phone:864-457-4500
Mailing Address - Fax:864-457-2195
Practice Address - Street 1:1504 E RUTHERFORD ST
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356-1416
Practice Address - Country:US
Practice Address - Phone:864-457-4500
Practice Address - Fax:864-457-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4059Medicaid
SCGP4059Medicaid
SC2322751Medicare PIN