Provider Demographics
NPI:1912094301
Name:BLACKSTONE, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-0647
Mailing Address - Country:US
Mailing Address - Phone:910-483-7337
Mailing Address - Fax:910-483-0648
Practice Address - Street 1:3505 CONVERSE DR
Practice Address - Street 2:STE 200
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6132
Practice Address - Country:US
Practice Address - Phone:910-392-5634
Practice Address - Fax:910-392-5654
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC17469208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4359214OtherAETNA
NC8915986Medicaid
NC1542826OtherWELLPATH
NC1912094301OtherDOCTORS DIRECT
NC15986OtherBCBS OF NC
NC1912094301OtherHEALTHNET FEDERAL SERVICES
NC1912094301OtherHUMANA
NC296275OtherMEDCOST
NCFH1101875OtherFIRST CAROLINA CARE
NC12337276OtherMULTIPLAN
NC4550753OtherCOVENTRY NATIONAL - COVENTRY PPO
NC1409483OtherUNITED HEALTHCARE
NC1542826OtherCOVENTRY OF THE CAROLINAS
NC1791139OtherCIGNA GREATWEST
NC1912094301OtherHEALTHSMART
NC1912094301Medicaid
NC1791139OtherCIGNA GREATWEST