Provider Demographics
NPI:1457324907
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/PHYSICIAN
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 1:457B HIGHWAY 123
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-0842
Mailing Address - Country:US
Mailing Address - Phone:864-888-4464
Mailing Address - Fax:864-888-4462
Practice Address - Street 1:457-B HIGHWAY 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:2006-02-07
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2466012080A0000X
SC1017942080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC195Medicaid
SCGP1060Medicaid