Provider Demographics
NPI:1285843888
Name:J WAID BLACKSTONE, M.D., LLC
Entity Type:Organization
Organization Name:J WAID BLACKSTONE, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WAID
Authorized Official - Last Name:BLACKSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-245-5203
Mailing Address - Street 1:210 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2924
Mailing Address - Country:US
Mailing Address - Phone:256-245-5203
Mailing Address - Fax:256-245-5981
Practice Address - Street 1:210 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2924
Practice Address - Country:US
Practice Address - Phone:256-245-5203
Practice Address - Fax:256-245-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24790261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7514689OtherAETNA
AL7514689OtherAETNA
AL=========OtherTRICARE