Provider Demographics
NPI:1851480396
Name:BLACKMON, BENJAMIN B JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:B
Last Name:BLACKMON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2344
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-2344
Mailing Address - Country:US
Mailing Address - Phone:803-254-2394
Mailing Address - Fax:803-254-7125
Practice Address - Street 1:TAYLOR AT MATION ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29220-0001
Practice Address - Country:US
Practice Address - Phone:803-254-2394
Practice Address - Fax:203-254-7125
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10460207LC0200X, 207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Not Answered207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC104602Medicaid
SC77778OtherMEDCOST
SC4129447OtherAETNA
SC104602OtherSELECT HEALTH
SC2000024OtherCCP
SC77778OtherMEDCOST