Provider Demographics
NPI:1194180331
Name:BLACKWELL, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4333 BENT RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35216-5313
Mailing Address - Country:US
Mailing Address - Phone:205-420-3565
Mailing Address - Fax:
Practice Address - Street 1:2700 10TH AVE S
Practice Address - Street 2:STE 200
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1200
Practice Address - Country:US
Practice Address - Phone:205-938-7838
Practice Address - Fax:205-683-2468
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
AL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical