Provider Demographics
NPI:1720153539
Name:DR SUMPTER D BLACKMON PA
Entity Type:Organization
Organization Name:DR SUMPTER D BLACKMON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMPTER
Authorized Official - Middle Name:DUDLEY
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-682-4128
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AL
Mailing Address - Zip Code:36726-0699
Mailing Address - Country:US
Mailing Address - Phone:334-682-4128
Mailing Address - Fax:334-682-9151
Practice Address - Street 1:321 WHISKEY RUN RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AL
Practice Address - Zip Code:36726-2303
Practice Address - Country:US
Practice Address - Phone:334-682-4128
Practice Address - Fax:334-682-9151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5754261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000000454Medicaid
ALC71994Medicare UPIN
AL000000454Medicare ID - Type Unspecified