Provider Demographics
NPI:1235118092
Name:BLUE, BRIAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:BLUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W MEETING ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-6219
Mailing Address - Country:US
Mailing Address - Phone:803-285-3700
Mailing Address - Fax:803-285-3715
Practice Address - Street 1:901 W MEETING ST
Practice Address - Street 2:SUITE 104
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6219
Practice Address - Country:US
Practice Address - Phone:803-285-3700
Practice Address - Fax:803-285-3715
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901507207X00000X
SC16798207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC571029311005OtherBCBS
SC904051OtherPPNI
SCTL8382Medicaid
SC571029311006OtherBCBS
SC9921493OtherCIGNA
SC4457436OtherAETNA
NC8912370Medicaid
SC01196446OtherAMERIGROUP
SC9921493OtherCIGNA
NCF59746Medicare UPIN
NC8912370Medicaid