Provider Demographics
NPI:1265043897
Name:BLACKSTONE MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:BLACKSTONE MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICK
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-831-2727
Mailing Address - Street 1:4030 HENDERSON BLVD STE 145
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-4940
Mailing Address - Country:US
Mailing Address - Phone:813-831-2727
Mailing Address - Fax:813-425-9025
Practice Address - Street 1:4000 BLACKBURN LN STE 210
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-6128
Practice Address - Country:US
Practice Address - Phone:240-390-3136
Practice Address - Fax:240-390-3168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic