Provider Demographics
NPI:1770632077
Name:BLUE RIDGE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:M.HISHAM
Authorized Official - Middle Name:ABDEL-AZIZ
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-789-0909
Mailing Address - Street 1:3214 CHARLES B ROOT WYND
Mailing Address - Street 2:SUITE 217
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5440
Mailing Address - Country:US
Mailing Address - Phone:919-789-0909
Mailing Address - Fax:919-789-9168
Practice Address - Street 1:3214 CHARLES B ROOT WYND
Practice Address - Street 2:SUITE 217
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5440
Practice Address - Country:US
Practice Address - Phone:919-789-0909
Practice Address - Fax:919-789-9168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501610261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891116AMedicaid
NC2250087Medicare ID - Type Unspecified
NC891116AMedicaid