Healthcare Provider Details

I. General information

NPI: 1407964646
Provider Name (Legal Business Name): BLUE RIDGE ANESTHESIA ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11116 MEDICAL CAMPUS ROAD
HAGERSTOWN MD
21742-6710
US

IV. Provider business mailing address

PO BOX 1248
HAGERSTOWN MD
21741-1248
US

V. Phone/Fax

Practice location:
  • Phone: 301-665-1717
  • Fax: 301-665-1810
Mailing address:
  • Phone: 301-665-1717
  • Fax: 301-665-1810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateMD

VIII. Authorized Official

Name: DR. CARLO JOHN CUTLER
Title or Position: DEPARTMENT HEAD
Credential: D.O.
Phone: 301-665-1717