Provider Demographics
NPI:1891883989
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:HILDEBRAN-ICARD MEDICAL CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FRITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-580-5455
Mailing Address - Street 1:517 MAIN AVE. WEST
Mailing Address - Street 2:
Mailing Address - City:HILDEBRAN
Mailing Address - State:NC
Mailing Address - Zip Code:28637
Mailing Address - Country:US
Mailing Address - Phone:828-397-5561
Mailing Address - Fax:828-397-3226
Practice Address - Street 1:517 MAIN AVE. WEST
Practice Address - Street 2:
Practice Address - City:HILDEBRAN
Practice Address - State:NC
Practice Address - Zip Code:28637
Practice Address - Country:US
Practice Address - Phone:828-397-5561
Practice Address - Fax:828-397-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2327875Medicare PIN