Provider Demographics
NPI:1295073070
Name:JACK H BLALOCK JR, MD, PC
Entity type:Organization
Organization Name:JACK H BLALOCK JR, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-327-4317
Mailing Address - Street 1:2300 MANCHESTER EXPY
Mailing Address - Street 2:STE F1
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6802
Mailing Address - Country:US
Mailing Address - Phone:706-660-8505
Mailing Address - Fax:706-660-1454
Practice Address - Street 1:2300 MANCHESTER EXPY
Practice Address - Street 2:STE F1
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6802
Practice Address - Country:US
Practice Address - Phone:706-660-8505
Practice Address - Fax:706-660-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012675207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D39427Medicare UPIN