Provider Demographics
NPI:1891760211
Name:BLACKSTONE, BRUCE GRAGG (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GRAGG
Last Name:BLACKSTONE
Suffix:
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 1:625 9TH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2465
Mailing Address - Country:US
Mailing Address - Phone:360-501-3400
Mailing Address - Fax:360-423-6862
Practice Address - Street 1:625 9TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2465
Practice Address - Country:US
Practice Address - Phone:360-501-3400
Practice Address - Fax:360-423-6862
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020762207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1131101Medicaid
OR195560Medicaid
WA1131101Medicaid
A08174Medicare UPIN