1386846871 NPI number — LISA R BLACKRICK MD

Table of content: LISA R BLACKRICK MD (NPI 1386846871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386846871 NPI number — LISA R BLACKRICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKRICK
Provider First Name:
LISA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1386846871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31808-0370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
706-494-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3627 UNIVERSITY BLVD S STE 550
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-7401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-379-5986
Provider Business Practice Location Address Fax Number:
904-551-0282
Provider Enumeration Date:
06/05/2007

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: 207XX0801X , with the licence number:  ME144788 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 105977400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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