Provider Demographics
NPI:1407887201
Name:BLACKWELL, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9263 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-7109
Mailing Address - Country:US
Mailing Address - Phone:843-414-1224
Mailing Address - Fax:843-414-1226
Practice Address - Street 1:9263 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-7109
Practice Address - Country:US
Practice Address - Phone:843-414-1224
Practice Address - Fax:843-414-1226
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA057150208100000X
SC29700208100000X, 2081P2900X
TN532812081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC297002Medicaid
I17540Medicare UPIN
SC297002Medicaid