NPIMap

Organization Active NPI

Blue Ridge Pediatrics LLC

  • Rural Health Clinic/Center
  • Seneca, SC
National Provider Identifier
1104130376
Registry record updated Jul 30, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
261QR1300X Issued in SC
Legal business name
BLUE RIDGE PEDIATRICS LLC
Practice address
457B Highway 123
Seneca, SC 29678-0842
Phone
(864) 888-4464
NPI assigned
Jul 30, 2010
Last updated
Jul 30, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 30, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Carey Molin Gully, MDNPI 1326066564
Title
Owner
Phone
(864) 888-4464

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 261QR1300X SC Primary

Addresses

Primary practice location

457B Highway 123
Seneca, SC 29678-0842

Mailing address

457B Highway 123
Seneca, SC 29678-0842
Phone (864) 888-4464

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091231000362 SC Part A Provider - Rural Health Clinic 6709927486 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Seneca, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104130376. Details of each certification follow.

Rural health clinic certification: CCN 428933

Legal name
BLUE RIDGE PEDIATRICS LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 5, 1999
Last certification
Nov 21, 2023
Ownership / control type
1B
Most recent change of ownership
Aug 1, 2009 (1 total)
Organization structure
CorporationProprietary
Incorporated
May 15, 2009 in SC
Enrollment address
457 Hwy 123 Bypass
B
Seneca, SC 29678-0842

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Blue Ridge Pediatrics LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

457 Bypass Highway 123
#B
Seneca, SC 29678
Phone (864) 888-4464

457B Highway 123
Seneca, SC 29678
Phone (864) 888-4464

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Barbara L Steely Individual Operational/Managerial Control Mar 12, 2014 100%
Carey M Gully Individual 5% Or Greater Direct Ownership Interest Aug 1, 2009 100%

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1280448000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1280448000000",
    "number": "1104130376",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "457B HIGHWAY 123",
            "city": "SENECA",
            "state": "SC",
            "postal_code": "296780842",
            "telephone_number": "864-888-4464"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "457B HIGHWAY 123",
            "city": "SENECA",
            "state": "SC",
            "postal_code": "296780842",
            "telephone_number": "864-888-4464"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE RIDGE PEDIATRICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-07-30",
        "last_updated": "2010-07-30",
        "status": "A",
        "authorized_official_last_name": "GULLY",
        "authorized_official_first_name": "CAREY",
        "authorized_official_middle_name": "MOLIN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "864-888-4464",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "SC",
            "license": "261QR1300X",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Seneca, SC

Sources for this page

Verify at the official NPI Registry.