=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154450757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE PEDIATRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 06/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 457 B HWY 123 BYPASS
-----------------------------------------------------
City | SENECA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-888-4464
-----------------------------------------------------
Fax | 864-888-4462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 457-B HWY 123 BYPASS
-----------------------------------------------------
City | SENECA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29678-0947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-888-4464
-----------------------------------------------------
Fax | 864-888-4462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CAREY MOLIN GULLY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 864-888-4464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------