Provider Demographics
NPI:1497766588
Name:BLACKSTONE, CONNIE J (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:BLACKSTONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:CONNIE
Other - Middle Name:L
Other - Last Name:JUMPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:404 SE MAIN STREET
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-0279
Mailing Address - Country:US
Mailing Address - Phone:864-963-8002
Mailing Address - Fax:864-963-2742
Practice Address - Street 1:404 SE MAIN STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-0279
Practice Address - Country:US
Practice Address - Phone:864-963-8002
Practice Address - Fax:864-963-2742
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15537207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC155370Medicaid
SC576007863095OtherBCBS
SC576007863095OtherBCBS
SCF040136699Medicare PIN
SCF04013Medicare UPIN
SCF040133640Medicare PIN