Provider Demographics
NPI:1760167233
Name:BLUE WAVE MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BLUE WAVE MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:Z
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-576-7624
Mailing Address - Street 1:28 CAVALRY RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-1401
Mailing Address - Country:US
Mailing Address - Phone:917-576-7624
Mailing Address - Fax:203-286-1282
Practice Address - Street 1:1822 DREW ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2921
Practice Address - Country:US
Practice Address - Phone:917-576-7624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury MedicineGroup - Multi-Specialty