Provider Demographics
NPI:1275196776
Name:BLUE, CAROL SUE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:SUE
Last Name:BLUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 N PORTAGE PATH
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-5832
Mailing Address - Country:US
Mailing Address - Phone:330-310-6186
Mailing Address - Fax:330-762-0924
Practice Address - Street 1:1288 N PORTAGE PATH
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5832
Practice Address - Country:US
Practice Address - Phone:330-310-6186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRF460445343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)