Basic Information
| Provider Information | |||||||||
| NPI: | 1063838712 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE RIDGE REGIONAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUE RIDGE SPECIALTY SERVICES-YANCEY CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131500 | ||||||||
| FaxNumber: | 8286516570 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287149010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286820200 | ||||||||
| FaxNumber: | 8286824171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2014 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | CLINT | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8286595196 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLUE RIDGE REGIONAL HOSPITAL, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.