=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407964646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE ANESTHESIA ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2006
-----------------------------------------------------
Last Update Date | 05/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11116 MEDICAL CAMPUS ROAD
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21742-6710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-665-1717
-----------------------------------------------------
Fax | 301-665-1810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1248
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21741-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-665-1717
-----------------------------------------------------
Fax | 301-665-1810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEPARTMENT HEAD
-----------------------------------------------------
Name | DR. CARLO JOHN CUTLER
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 301-665-1717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------