Provider Demographics
NPI:1801953765
Name:BLYSTONE, SHERMAN B JR (PT)
Entity type:Individual
Prefix:MR
First Name:SHERMAN
Middle Name:B
Last Name:BLYSTONE
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-2114
Mailing Address - Fax:252-338-2115
Practice Address - Street 1:101 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-2114
Practice Address - Fax:252-338-2115
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0779VOtherBCBS
NC271572BOtherMEDICARE PART B GROUP
NC720779VMedicaid
NC720779VMedicaid
NC250040BMedicare PIN