Provider Demographics
NPI:1104036367
Name:PABLO VALLE BLACIO, MD, LLC
Entity Type:Organization
Organization Name:PABLO VALLE BLACIO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-235-0717
Mailing Address - Street 1:1101 CHRISTINE AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-4657
Mailing Address - Country:US
Mailing Address - Phone:256-235-0717
Mailing Address - Fax:256-235-0719
Practice Address - Street 1:1101 CHRISTINE AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4657
Practice Address - Country:US
Practice Address - Phone:256-235-0717
Practice Address - Fax:256-235-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL204762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000000979Medicaid
AL51000979OtherBLUECROSSBLUESHIELDOFALAB
AL000000979Medicaid