Provider Demographics
NPI:1770545550
Name:BLUE RIDGE DERMATOLOGY ASSOCIATES
Entity type:Organization
Organization Name:BLUE RIDGE DERMATOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:AMSDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-781-1050
Mailing Address - Street 1:4225 MACON POND RD STE 300
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6320
Mailing Address - Country:US
Mailing Address - Phone:919-781-1050
Mailing Address - Fax:919-510-5090
Practice Address - Street 1:4225 MACON POND RD STE 300
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6320
Practice Address - Country:US
Practice Address - Phone:919-781-1050
Practice Address - Fax:919-510-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901073Medicaid
NC8901073Medicaid