Provider Demographics
NPI:1821083551
Name:BLUE RIDGE DERMATOLOGY PA
Entity Type:Organization
Organization Name:BLUE RIDGE DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-456-7343
Mailing Address - Street 1:540 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-8027
Mailing Address - Country:US
Mailing Address - Phone:828-456-7343
Mailing Address - Fax:828-452-0939
Practice Address - Street 1:540 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-8027
Practice Address - Country:US
Practice Address - Phone:828-456-7343
Practice Address - Fax:828-452-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0122KOtherBLUE CROSS BLUE SHIELD
NC890122KMedicaid
0122KOtherBLUE CROSS BLUE SHIELD
NC890122KMedicaid