Provider Demographics
NPI:1558492017
Name:SOUTH CENTRAL GI, LLC
Entity Type:Organization
Organization Name:SOUTH CENTRAL GI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-623-7800
Mailing Address - Street 1:124 SAWTOOTH OAK ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-7160
Mailing Address - Country:US
Mailing Address - Phone:501-623-7800
Mailing Address - Fax:
Practice Address - Street 1:124 SAWTOOTH OAK ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7160
Practice Address - Country:US
Practice Address - Phone:501-623-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126541001Medicaid
AR146525002Medicaid
AR5K269Medicare ID - Type UnspecifiedTERRI BLACKSTOCK MD
AR126541001Medicaid
AR5J570Medicare ID - Type UnspecifiedBRENDA KETCHER MD
ARF94313Medicare UPIN