Basic Information
| Provider Information | |||||||||
| NPI: | 1275579997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 900 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211580900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108716502 | ||||||||
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| Practice Location | |||||||||
| Address1: | 844 WASHINGTON ROAD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108710088 | ||||||||
| FaxNumber: | 4108710083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/11/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | D50329 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | D0050329 | MD | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 811900700 | 05 | MD | MEDICAID |