Provider Demographics
NPI:1679735112
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:BLUE RIDGE NEPHROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP-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:PO BOX 601076
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1076
Mailing Address - Country:US
Mailing Address - Phone:828-580-3250
Mailing Address - Fax:828-580-3251
Practice Address - Street 1:352 E PARKER RD STE B
Practice Address - Street 2:SUITE A
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-5122
Practice Address - Country:US
Practice Address - Phone:828-580-3250
Practice Address - Fax:828-580-3251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300065207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950781Medicaid
NC2327875Medicare PIN