MEDICARE: BLUHAVEN HEALTH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363L00000X	Nurse Practitioner
2	207Y00000X	Otolaryngology Physician
3	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1083456446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUHAVEN HEALTH PA

Provider Business Mailing Address
First Line	:	4109 WAKE FOREST RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-2510
Country	:	US
Telephone Number	:	984-370-2350
Fax Number	:	984-370-2352

Provider Business Practice Location Address
First Line	:	4109 WAKE FOREST RD STE 220
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-2510
Country	:	US
Telephone Number	:	984-370-2350
Fax Number	:	984-370-2352

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CHARLIE FRYE
Credential	:
Telephone Number	:	984-370-2350

Provider Enumeration Date	:	06/07/2024
Last Update Date	:	10/29/2024

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Directions to “BLUHAVEN HEALTH PA ” Practice Location

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