Provider Demographics
NPI:1730112434
Name:BLUE RIDGE SURGICAL GROUP, PA
Entity Type:Organization
Organization Name:BLUE RIDGE SURGICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-268-0688
Mailing Address - Street 1:838 STATE FARM ROAD, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607
Mailing Address - Country:US
Mailing Address - Phone:828-268-0688
Mailing Address - Fax:828-268-0413
Practice Address - Street 1:838 STATE FARM ROAD, SUITE 1
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607
Practice Address - Country:US
Practice Address - Phone:828-268-0688
Practice Address - Fax:828-268-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500690208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0267WOtherBCBS
NC890267WMedicaid
0267WOtherBCBS
0267WOtherBCBS
NCG04472Medicare UPIN