Provider Demographics
NPI:1326353798
Name:BLAYLOCK MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:BLAYLOCK MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:N
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-332-7211
Mailing Address - Street 1:130 E WALKER ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-4766
Mailing Address - Country:US
Mailing Address - Phone:662-332-7211
Mailing Address - Fax:662-332-0442
Practice Address - Street 1:130 E WALKER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4766
Practice Address - Country:US
Practice Address - Phone:662-332-7211
Practice Address - Fax:662-332-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04644261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care