Basic Information
| Provider Information | |||||||||
| NPI: | 1134149990 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE MOUNTAIN UROLOGY, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VERGAS & STEELE, PLLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 BRETTWOOD TRCE | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287218021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284529700 | ||||||||
| FaxNumber: | 8284523701 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 BRETTWOOD TRCE | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287218021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284529700 | ||||||||
| FaxNumber: | 8284523701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 04/07/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEELE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | HENRY | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8284529700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 9600227 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 208800000X | 96-00227 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 89013YY | 05 | NC | MEDICAID |