1477507994 NPI number — WILLIAM S BLAKEMORE MD LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477507994 NPI number — WILLIAM S BLAKEMORE MD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM S BLAKEMORE MD LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1477507994
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 MARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDENTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27932-1704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-482-7471
Provider Business Mailing Address Fax Number:
252-482-5465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 MARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDENTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27932-1704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-482-7471
Provider Business Practice Location Address Fax Number:
252-482-5465
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKEMORE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT CORP.
Authorized Official Telephone Number:
252-482-7471

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  24730 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 890131V , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0131V . This is a "BLUE CROSS GROUP NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CG5520 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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