Provider Demographics
NPI:1952626384
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC
Other - Org Name:TABLE ROCK FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5472
Mailing Address - Street 1:301 LINVILLE ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-7206
Mailing Address - Country:US
Mailing Address - Phone:828-584-2481
Mailing Address - Fax:828-584-8371
Practice Address - Street 1:301 LINVILLE STREET
Practice Address - Street 2:
Practice Address - City:GLEN ALPINE
Practice Address - State:NC
Practice Address - Zip Code:28628
Practice Address - Country:US
Practice Address - Phone:828-584-2481
Practice Address - Fax:828-584-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
204D00000X
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2006-01695OtherNC LLICENSE
NC2327875GMedicare PIN