Basic Information
| Provider Information | |||||||||
| NPI: | 1992186092 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE RIDGE REGIONAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MISSION COMMUNITY OBSTETRICS AND GYNECOLOGY SPECIALIST | ||||||||
| 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: | 125 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SPRUCE PINE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287773035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287663001 | ||||||||
| FaxNumber: | 8287663787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | CLINT | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8287663010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.