Provider Demographics
NPI:1902069693
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:BLUE RIDGE DIGESTIVE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP-CFA
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:8285-806-5545
Mailing Address - Street 1:2209 S STERLING ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-4091
Mailing Address - Country:US
Mailing Address - Phone:828-580-6752
Mailing Address - Fax:828-580-6754
Practice Address - Street 1:2209 S STERLING ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4091
Practice Address - Country:US
Practice Address - Phone:828-580-6752
Practice Address - Fax:828-580-6754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200800387207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950509Medicaid
NC5950509Medicaid