1104903020 NPI number — MR. WILLIAM RUSSELL BLAYLOCK OTR

Table of content: MR. WILLIAM RUSSELL BLAYLOCK OTR (NPI 1104903020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104903020 NPI number — MR. WILLIAM RUSSELL BLAYLOCK OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAYLOCK
Provider First Name:
WILLIAM
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTR
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:
1104903020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1803 PEACH TREE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-492-0383
Provider Business Mailing Address Fax Number:
972-492-2074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1912 E HEBRON PKWY
Provider Second Line Business Practice Location Address:
#104
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-492-0383
Provider Business Practice Location Address Fax Number:
972-492-2074
Provider Enumeration Date:
11/01/2006

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: 225X00000X , with the licence number:  103091 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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