Provider Demographics
NPI:1457444671
Name:BLACKINGTON, MARY REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:REBECCA
Last Name:BLACKINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11525 HAYNES BRIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-4822
Mailing Address - Country:US
Mailing Address - Phone:770-751-0800
Mailing Address - Fax:770-751-1401
Practice Address - Street 1:11525 HAYNES BRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-4822
Practice Address - Country:US
Practice Address - Phone:770-751-0800
Practice Address - Fax:770-751-1401
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051424208000000X
GA43554208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134985CMedicaid