Provider Demographics
NPI:1366491342
Name:BLOUIN, RANDALL RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:RICHARD
Last Name:BLOUIN
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A350
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-5110
Practice Address - Fax:864-454-5141
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8372208000000X, 2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4304559OtherAETNA
SC57-6007863080OtherBCBS OF SC
SC083723Medicaid
SC57-6007863037OtherBLUE CHOICE OF SC
SC1385497OtherCIGNA
SC57-6007863037OtherBLUE CHOICE OF SC
SC4304559OtherAETNA
SCD174776904Medicare PIN