Provider Demographics
NPI:1912994583
Name:BLACKSTONE, JR., JACK C (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:C
Last Name:BLACKSTONE, JR.
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1000 BRECKENRIDGE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-0839
Mailing Address - Country:US
Mailing Address - Phone:270-926-3700
Mailing Address - Fax:270-926-2114
Practice Address - Street 1:1000 BRECKENRIDGE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-0839
Practice Address - Country:US
Practice Address - Phone:270-926-3700
Practice Address - Fax:270-926-2114
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2010-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY18142207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64181423Medicaid
KY64181423Medicaid
KY0504402Medicare ID - Type Unspecified