Active NPI
Blue Ridge Pediatrics LLC
- Rural Health Clinic/Center
- Seneca, SC
National Provider Identifier
1154450757
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Rural Health Clinic/Center
- Legal business name
- BLUE RIDGE PEDIATRICS LLC
- Practice address
- 457 B Hwy 123 Bypass
Seneca, SC 29678 - Phone
- (864) 888-4464
- Fax
- (864) 888-4462
- NPI assigned
- Mar 2, 2007
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Carey Molin Gully, MD
- Title
- Owner
- Phone
- (864) 888-4464
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Primary |
Addresses
Primary practice location
457 B Hwy 123 Bypass
Seneca, SC 29678
Mailing address
457-B Hwy 123 Bypass
Seneca, SC 29678-0947
Phone (864) 888-4464
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| RHC 100 | Other | SC | RURAL HEALTH CLINIC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SC
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20091231000362 | SC | Part A Provider - Rural Health Clinic | 6709927486 |
1 other NPI on this enrollment Practice locations: Seneca, SC |
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
- Corporation
- 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 LLC
Other organizations with this tax ID 2
Organizations that report the same tax identification number in the National Provider Directory.
-
- Rural Health Clinic/Center
- Seneca, SC
- NPI 1104130376
-
- Pediatric Adolescent Medicine Physician
- Seneca, SC
- NPI 1457324907
Locations
457 Bypass Highway 123
#B
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.
| Name | Role | Since | Share |
|---|---|---|---|
| Barbara L Steely | Operational/Managerial Control | Mar 12, 2014 | 100% |
| Carey M Gully | 5% Or Greater Direct Ownership Interest | Aug 1, 2009 | 100% |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172793600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1246320000000",
"number": "1154450757",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "457-B HWY 123 BYPASS",
"city": "SENECA",
"state": "SC",
"postal_code": "296780947",
"telephone_number": "864-888-4464",
"fax_number": "864-888-4462"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "457 B HWY 123 BYPASS",
"city": "SENECA",
"state": "SC",
"postal_code": "29678",
"telephone_number": "864-888-4464",
"fax_number": "864-888-4462"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "BLUE RIDGE PEDIATRICS LLC",
"organizational_subpart": "NO",
"enumeration_date": "2007-03-02",
"last_updated": "2009-06-30",
"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_name_prefix": "Dr.",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "261QR1300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Rural Health",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RURAL HEALTH CLINIC",
"identifier": "RHC 100",
"state": "SC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Seneca, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 30, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.