Provider Demographics
NPI:1659806248
Name:BLUFF DRIVE MEDICAL
Entity Type:Organization
Organization Name:BLUFF DRIVE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:678-897-9577
Mailing Address - Street 1:954 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2334
Mailing Address - Country:US
Mailing Address - Phone:678-897-9577
Mailing Address - Fax:
Practice Address - Street 1:954 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2334
Practice Address - Country:US
Practice Address - Phone:678-897-9577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003951363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty