Provider Demographics
NPI:1104559160
Name:BLUE LOT MD PLLC
Entity type:Organization
Organization Name:BLUE LOT MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LETITIA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:TIERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-344-2345
Mailing Address - Street 1:10 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2699
Mailing Address - Country:US
Mailing Address - Phone:304-344-2345
Mailing Address - Fax:304-400-4645
Practice Address - Street 1:10 COURTNEY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2699
Practice Address - Country:US
Practice Address - Phone:304-344-2345
Practice Address - Fax:304-400-4645
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE LOT MD PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-07
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810017636Medicaid