Provider Demographics
NPI:1598918526
Name:BLUE PLASTIC SURGERY CENTER PLLC
Entity Type:Organization
Organization Name:BLUE PLASTIC SURGERY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:LUTHER
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-235-6610
Mailing Address - Street 1:134 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5599
Mailing Address - Country:US
Mailing Address - Phone:704-235-6610
Mailing Address - Fax:704-235-6615
Practice Address - Street 1:134 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5599
Practice Address - Country:US
Practice Address - Phone:704-235-6610
Practice Address - Fax:704-235-6615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-1317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty