Provider Demographics
NPI:1629138946
Name:BLUE RIDGE FAMILY PRACTICE & SPORTS MEDICINE, P.A.
Entity Type:Organization
Organization Name:BLUE RIDGE FAMILY PRACTICE & SPORTS MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:MARNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-298-7972
Mailing Address - Street 1:942 TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-2025
Mailing Address - Country:US
Mailing Address - Phone:828-298-7972
Mailing Address - Fax:828-298-6637
Practice Address - Street 1:942 TUNNEL RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2025
Practice Address - Country:US
Practice Address - Phone:828-298-7972
Practice Address - Fax:828-298-6637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500655261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0101YOtherBCBS OF NC GROUP
NC54940OtherBCBS OF NC INDIVIDUAL
NC790101YMedicaid
NC8954940Medicaid
NC790101YMedicaid
NC0101YOtherBCBS OF NC GROUP
NCG23667Medicare UPIN