Provider Demographics
NPI:1255751525
Name:BLACKWELL, KORY
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SOUTH 28TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401
Mailing Address - Country:US
Mailing Address - Phone:601-579-5463
Mailing Address - Fax:
Practice Address - Street 1:5192 OLD HIGHWAY 11 STE 2
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-6222
Practice Address - Country:US
Practice Address - Phone:601-268-0929
Practice Address - Fax:601-261-0508
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08076764Medicaid