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General NPI Number Information
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NPI Number | 1861686313
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Entity Type | Organization
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Legal Business Name | BLUE HERON MEDICAL GROUP LLC
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Dates
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Enumeration Date | 08/28/2007
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Last Update Date | 03/01/2012
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Provider Practice Location Address
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Address Line | 305 10TH ST STE 101
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City | POCOMOKE CITY
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State | MD
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Zip | 21851-1607
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Country | US
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Telephone | 410-957-3005
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Fax | 410-957-0550
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Provider Business Mailing Address
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Address Line | 305 10TH ST STE 101
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City | POCOMOKE CITY
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State | MD
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Zip | 21851-1607
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Country | US
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Telephone | 410-957-3005
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Fax | 410-957-0550
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. PAUL REARDON FLEURY
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Credential | M.D.
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Telephone | 410-957-3005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | D058928
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | D45995
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | D24871
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License Number State | MD
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | D36576
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License Number State | MD
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Taxonomy #5
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | Q37875
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License Number State | MD
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Taxonomy #6
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | D24872
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License Number State | MD
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