1235118092 NPI number — BRIAN A BLUE MD

Table of content: BRIAN A BLUE MD (NPI 1235118092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235118092 NPI number — BRIAN A BLUE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLUE
Provider First Name:
BRIAN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235118092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 W MEETING ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29720-6219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-285-3700
Provider Business Mailing Address Fax Number:
803-285-3715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 W MEETING ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29720-6219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-285-3700
Provider Business Practice Location Address Fax Number:
803-285-3715
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  9901507 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 16798 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 571029311005 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 904051 . This is a "PPNI" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: TL8382 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 571029311006 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 9921493 . This is a "CIGNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 4457436 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 8912370 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01196446 . This is a "AMERIGROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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