Basic Information
| Provider Information | |||||||||
| NPI: | 1104130376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE PEDIATRICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 457B HIGHWAY 123 | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296780842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648884464 | ||||||||
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| Practice Location | |||||||||
| Address1: | 457B HIGHWAY 123 | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296780842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648884464 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2010 | ||||||||
| LastUpdateDate: | 07/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | GULLY | ||||||||
| AuthorizedOfficialFirstName: | CAREY | ||||||||
| AuthorizedOfficialMiddleName: | MOLIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8648884464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 261QR1300X | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC195 | 05 | SC | MEDICAID |