Healthcare Provider Details

I. General information

NPI: 1457324907
Provider Name (Legal Business Name): BLUE RIDGE PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457-B HIGHWAY 123 BYPASS
SENECA SC
29678
US

IV. Provider business mailing address

457B HIGHWAY 123
SENECA SC
29678-0842
US

V. Phone/Fax

Practice location:
  • Phone: 864-888-4464
  • Fax: 864-888-4462
Mailing address:
  • Phone: 864-888-4464
  • Fax: 864-888-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number101794
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number246601
License Number StateSC

VIII. Authorized Official

Name: DR. CAREY MOLIN GULLY
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 864-888-4464