Provider Demographics
NPI:1508113309
Name:BLUE SEA MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BLUE SEA MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:AYUB
Authorized Official - Last Name:MAZHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-256-7520
Mailing Address - Street 1:112 SEZANNE CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-5095
Mailing Address - Country:US
Mailing Address - Phone:501-256-7520
Mailing Address - Fax:
Practice Address - Street 1:1401 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3720
Practice Address - Country:US
Practice Address - Phone:501-985-2537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3012207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARG32526Medicare UPIN