Basic Information
| Provider Information | |||||||||
| NPI: | 1477526689 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE BLUE RIDGE CLEMSON ORTHOPAEDIC ASC LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLUE RIDGE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10630 CLEMSON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296784545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644825100 | ||||||||
| FaxNumber: | 8644829100 | ||||||||
| Practice Location | |||||||||
| Address1: | 10630 CLEMSON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296784545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644825100 | ||||||||
| FaxNumber: | 8644829100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ASF-068 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | ASC040 | 05 | SC | MEDICAID |