Provider Demographics
NPI:1861686313
Name:BLUE HERON MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:BLUE HERON MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:REARDON
Authorized Official - Last Name:FLEURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-957-3005
Mailing Address - Street 1:305 10TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:POCOMOKE CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21851-1607
Mailing Address - Country:US
Mailing Address - Phone:410-957-3005
Mailing Address - Fax:410-957-0550
Practice Address - Street 1:305 10TH ST
Practice Address - Street 2:STE 101
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-1607
Practice Address - Country:US
Practice Address - Phone:410-957-3005
Practice Address - Fax:410-957-0550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD058928207Q00000X
MDD45995207Q00000X
MDD24872207R00000X
MDD24871207R00000X
MDD36576207R00000X
MDQ37875363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1841384625OtherNPI
MD1245292853OtherNPI
MD1639269368OtherNPI
MD1265491286OtherNPI
MD1669558227OtherNPI
MD1992764815OtherNPI
MDB06742Medicare UPIN
MD1669558227OtherNPI
MD1265491286OtherNPI
MD1841384625OtherNPI
MDB69459Medicare UPIN
MDB69808Medicare UPIN