Provider Demographics
NPI:1366003436
Name:BLACKWELL'S FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:BLACKWELL'S FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISOTPHER
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-377-1975
Mailing Address - Street 1:171 PIGOTT EASTERLING RD
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-7222
Mailing Address - Country:US
Mailing Address - Phone:601-303-8264
Mailing Address - Fax:
Practice Address - Street 1:107 BALL AVE
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2101
Practice Address - Country:US
Practice Address - Phone:601-303-8264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care