1720531577 NPI number — JAMES MADISON BLACKWELL PT, DPT

Table of content: JAMES MADISON BLACKWELL PT, DPT (NPI 1720531577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720531577 NPI number — JAMES MADISON BLACKWELL PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKWELL
Provider First Name:
JAMES
Provider Middle Name:
MADISON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1720531577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8823 PRODUCTION LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OOLTEWAH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37363-6511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:
423-362-8684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3480 KEITH BRIDGE RD
Provider Second Line Business Practice Location Address:
STE C2
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041-5568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-455-8773
Provider Business Practice Location Address Fax Number:
678-455-8775
Provider Enumeration Date:
07/28/2016

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: 225100000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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