Provider Demographics
NPI:1114970373
Name:BLACKWELL, ERIC SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:SCOTT
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:MSB 015
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-226-6933
Mailing Address - Fax:269-226-6949
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:MSB 015
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-226-6933
Practice Address - Fax:269-226-6949
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072041208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MI104275172Medicaid
MIEB072041OtherBLUE CROSS BLUE SHIELD
MI104277720Medicaid
MI4321103-10Medicaid
MI930102111Medicare PIN
H20237Medicare UPIN
MIG56008104Medicare ID - Type UnspecifiedTHREE RIVERS HEALTH
MI0M90900020Medicare PIN
MI104277720Medicaid
MI104275172Medicaid