Healthcare Provider Details

I. General information

NPI: 1861686313
Provider Name (Legal Business Name): BLUE HERON MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 10TH ST STE 101
POCOMOKE CITY MD
21851-1607
US

IV. Provider business mailing address

305 10TH ST STE 101
POCOMOKE CITY MD
21851-1607
US

V. Phone/Fax

Practice location:
  • Phone: 410-957-3005
  • Fax: 410-957-0550
Mailing address:
  • Phone: 410-957-3005
  • Fax: 410-957-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberQ37875
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD058928
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD45995
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD24871
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD36576
License Number StateMD
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD24872
License Number StateMD

VIII. Authorized Official

Name: DR. PAUL REARDON FLEURY
Title or Position: DOCTOR
Credential: M.D.
Phone: 410-957-3005