Provider Demographics
NPI:1245486067
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP-CFO
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:828-580-5003
Mailing Address - Street 1:2209 S STERLING ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-4091
Mailing Address - Country:US
Mailing Address - Phone:828-580-4661
Mailing Address - Fax:828-580-4698
Practice Address - Street 1:2209 S STERLING ST
Practice Address - Street 2:SUITE 400
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4091
Practice Address - Country:US
Practice Address - Phone:828-580-4661
Practice Address - Fax:828-580-4698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC23421OtherLICENSE
NC55709OtherLICENSE
NC200400734OtherLICENSE
NC121106OtherLICENSE
NC39990OtherLICENSE
NC100615OtherLICENSE
NC35513OtherLICENSE
NC5950522Medicaid
NC9800595OtherLICENSE
NC2327875CMedicare PIN