1437576568 NPI number — BLUE WATER MEDICAL, INC.

Table of content: (NPI 1437576568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437576568 NPI number — BLUE WATER MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE WATER MEDICAL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1437576568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922 GAINESLVILLE HWY
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-355-5398
Provider Business Mailing Address Fax Number:
888-974-6246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
922 GAINESVILLE HWY
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
BUFORD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30518-1642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-355-5398
Provider Business Practice Location Address Fax Number:
888-974-6246
Provider Enumeration Date:
03/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GUFFIN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-355-5398

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7202360001 . This is a "DMERC" identifier . This identifiers is of the category "OTHER".




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