Provider Demographics
NPI:1407887862
Name:JESSE A BLACKMAN, MD, PA
Entity Type:Organization
Organization Name:JESSE A BLACKMAN, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-242-5550
Mailing Address - Street 1:109 S. SYCAMORE STREET
Mailing Address - Street 2:P O BOX 878
Mailing Address - City:FREMONT
Mailing Address - State:NC
Mailing Address - Zip Code:27830
Mailing Address - Country:US
Mailing Address - Phone:919-242-5550
Mailing Address - Fax:919-242-6428
Practice Address - Street 1:109 S. SYCAMORE STREET
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NC
Practice Address - Zip Code:27830
Practice Address - Country:US
Practice Address - Phone:919-242-5550
Practice Address - Fax:919-242-6428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8916000Medicaid
NCC80790Medicare UPIN
NC8916000Medicaid