Provider Demographics
NPI:1366453458
Name:BLACKSTONE, MARCUS E (MD)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:E
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:404 SOUTHEAST MAIN ST
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681
Mailing Address - Country:US
Mailing Address - Phone:864-963-8002
Mailing Address - Fax:864-963-2742
Practice Address - Street 1:404 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2652
Practice Address - Country:US
Practice Address - Phone:864-963-8002
Practice Address - Fax:864-963-2742
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00446146OtherRR MEDICARE
SC187470Medicaid
SC18747OtherSTATE LICENSE #
SC576007863095OtherBCBS
SC187470Medicaid
SCG654123640Medicare PIN
SCP00446146OtherRR MEDICARE
SCG65412Medicare UPIN