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General NPI Number Information
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NPI Number | 1457324907
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE PEDIATRICS LLC
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Dates
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Enumeration Date | 02/07/2006
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Last Update Date | 01/25/2011
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Provider Practice Location Address
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Address Line | 457-B HIGHWAY 123 BYPASS
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City | SENECA
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State | SC
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Zip | 29678
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Country | US
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Telephone | 864-888-4464
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Fax | 864-888-4462
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Provider Business Mailing Address
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Address Line | 457B HIGHWAY 123
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City | SENECA
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State | SC
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Zip | 29678-0842
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Country | US
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Telephone | 864-888-4464
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Fax | 864-888-4462
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. CAREY MOLIN GULLY
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Credential | M.D.
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Telephone | 864-888-4464
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 101794
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 246601
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License Number State | SC
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