Provider Demographics
NPI:1154450757
Name:BLUE RIDGE PEDIATRICS LLC
Entity Type:Organization
Organization Name:BLUE RIDGE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:MOLIN
Authorized Official - Last Name:GULLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-888-4464
Mailing Address - Street 1:457-B HWY 123 BYPASS
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-0947
Mailing Address - Country:US
Mailing Address - Phone:864-888-4464
Mailing Address - Fax:864-888-4462
Practice Address - Street 1:457 B HWY 123 BYPASS
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678
Practice Address - Country:US
Practice Address - Phone:864-888-4464
Practice Address - Fax:864-888-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC 100OtherRURAL HEALTH CLINIC