Provider Demographics
NPI:1184640740
Name:ROURKE, BLAINE B (DO)
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:B
Last Name:ROURKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4607
Mailing Address - Country:US
Mailing Address - Phone:843-692-1752
Mailing Address - Fax:843-692-1904
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1752
Practice Address - Fax:843-692-1904
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03254363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L5723OtherMEDICARE PTAN
TX182196901Medicaid
TX182196901Medicaid