MEDICARE: MS. CAROLINE DUPUY BLIVEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	3738	GA

General Provider Information

NPI Number	:	1982772125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROLINE DUPUY BLIVEN PA-C

Provider Business Mailing Address
First Line	:	300 HOSPITAL RD. EAMC
Second Line	:	ATTN: CREDENTIALS
City	:	FT. GORDON
State	:	GA
Zip	:	30905-5650
Country	:	US
Telephone Number	:	706-787-8176
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 HOSPITAL RD.
Second Line	:	CONNELLY HEALTH CLINIC
City	:	FT GORDON
State	:	GA
Zip	:	30905-5650
Country	:	US
Telephone Number	:	706-787-1696
Fax Number	:	706-787-8176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	11/14/2013

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