Provider Demographics
NPI:1659300333
Name:BLUE RIDGE PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:BLUE RIDGE PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:OVERSTREET
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:828-697-3553
Mailing Address - Street 1:420 5TH AVE WEST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28739
Mailing Address - Country:US
Mailing Address - Phone:828-697-3553
Mailing Address - Fax:828-697-5153
Practice Address - Street 1:420 5TH AVE WEST
Practice Address - Street 2:SUITE 300
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739
Practice Address - Country:US
Practice Address - Phone:828-697-3553
Practice Address - Fax:828-697-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC013TEOtherBCBS
NC89013TEMedicaid
NC89013TEMedicaid