Provider Demographics
NPI:1740558949
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:ALAN F. JACKS, MD, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:FRITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-580-4661
Mailing Address - Street 1:845 MALCOLM BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD COLLEGE
Mailing Address - State:NC
Mailing Address - Zip Code:28671-2872
Mailing Address - Country:US
Mailing Address - Phone:828-874-0555
Mailing Address - Fax:828-874-2111
Practice Address - Street 1:845 MALCOLM BLVD
Practice Address - Street 2:
Practice Address - City:RUTHERFORD COLLEGE
Practice Address - State:NC
Practice Address - Zip Code:28671-0476
Practice Address - Country:US
Practice Address - Phone:828-874-0555
Practice Address - Fax:828-874-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC969601640208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2327875OtherMEDICARE PTAN