Healthcare Provider Details

I. General information

NPI: 1265021364
Provider Name (Legal Business Name): BLUE LAKE HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MEMORIAL DR
DALTON GA
30720-2529
US

IV. Provider business mailing address

DEPT #8318 PO BOX 11407
BIRMINGHAM AL
35246
US

V. Phone/Fax

Practice location:
  • Phone: 706-272-6000
  • Fax:
Mailing address:
  • Phone: 205-977-1949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E PATRICK JR.
Title or Position: CEO
Credential:
Phone: 205-977-1949