Provider Demographics
NPI:1356332100
Name:BLACKWELL, JACK THOMAS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:THOMAS
Last Name:BLACKWELL
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1499 FAIR RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1683
Mailing Address - Country:US
Mailing Address - Phone:912-486-1482
Mailing Address - Fax:912-871-2383
Practice Address - Street 1:415 EISENHOWER DR
Practice Address - Street 2:STE 6
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2600
Practice Address - Country:US
Practice Address - Phone:912-354-3510
Practice Address - Fax:912-356-3391
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-01
Last Update Date:2016-06-25
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Provider Licenses
StateLicense IDTaxonomies
GA023908207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology