1356411599 NPI number — DR. EDWARD RILEY BLOCKER M.D.

Table of content: DR. EDWARD RILEY BLOCKER M.D. (NPI 1356411599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356411599 NPI number — DR. EDWARD RILEY BLOCKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOCKER
Provider First Name:
EDWARD
Provider Middle Name:
RILEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1356411599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 WRIGHTS POINT CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29902-6955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-522-7100
Provider Business Mailing Address Fax Number:
843-322-3234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MIDTOWN DR
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
BEAUFORT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29906-5200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-522-7100
Provider Business Practice Location Address Fax Number:
843-322-3234
Provider Enumeration Date:
11/08/2006

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:  17331 , 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: G662416305 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 173314 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".