Provider Demographics
NPI:1295965614
Name:BLALACK, VIRGINIA ARRINGTON (MD)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ARRINGTON
Last Name:BLALACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 BROAD AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2464
Mailing Address - Country:US
Mailing Address - Phone:228-575-1400
Mailing Address - Fax:
Practice Address - Street 1:1340 BROAD AVE STE 310
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2464
Practice Address - Country:US
Practice Address - Phone:228-575-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2187207R00000X
MS22243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine