Basic Information
| Provider Information | |||||||||
| NPI: | 1407964646 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE RIDGE ANESTHESIA ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUE RIDGE ANESTHESIA, LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1248 | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217411248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016651717 | ||||||||
| FaxNumber: | 3016651810 | ||||||||
| Practice Location | |||||||||
| Address1: | 11116 MEDICAL CAMPUS ROAD | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217426710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016651717 | ||||||||
| FaxNumber: | 3016651810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 05/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | CUTLER | ||||||||
| AuthorizedOfficialFirstName: | CARLO | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | DEPARTMENT HEAD | ||||||||
| AuthorizedOfficialTelephone: | 3016651717 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207LP2900X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 452002500 | 05 | MD | MEDICAID | 0015906630005 | 05 | PA | MEDICAID |