Provider Demographics
NPI:1295723328
Name:BLALOCK, RICHARD E (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:BLALOCK
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 1:1000 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-9303
Mailing Address - Country:US
Mailing Address - Phone:270-759-9200
Mailing Address - Fax:270-759-9966
Practice Address - Street 1:1000 S 12TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-9303
Practice Address - Country:US
Practice Address - Phone:270-759-9200
Practice Address - Fax:270-759-9966
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64203417Medicaid
KY000000050313OtherANTHEM BC BS
KY110001757OtherRAILROAD MEDICARE
KY610994960OtherTAX ID
KY610994960OtherTAX ID
KY0283206Medicare PIN