Provider Demographics
NPI:1841532819
Name:BLACKSTOCK, DREW STEVEN (MD)
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:STEVEN
Last Name:BLACKSTOCK
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 1:6630 SUMMER KNOLL CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-2875
Mailing Address - Country:US
Mailing Address - Phone:901-746-9438
Mailing Address - Fax:
Practice Address - Street 1:6630 SUMMER KNOLL CIR STE 101
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134
Practice Address - Country:US
Practice Address - Phone:901-746-9438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51931207QA0401X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02237563Medicaid
MO1841532819Medicaid
TNQ008983Medicaid