Provider Demographics
NPI:1720159098
Name:BLOUNT, RONNIE (MD)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:
Last Name:BLOUNT
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 1:125 1ST ST
Mailing Address - Street 2:STE A
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2692
Mailing Address - Country:US
Mailing Address - Phone:478-787-6910
Mailing Address - Fax:478-254-5029
Practice Address - Street 1:125 FRIST ST
Practice Address - Street 2:STE A
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-787-6910
Practice Address - Fax:478-254-5029
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0397352084P0800X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000648161AMedicaid
GA26BDDZNMedicare PIN
GA000648161AMedicaid