Provider Demographics
NPI:1154743383
Name:BLALOCK, PHILIP DAVID I (SPEECH PATHOLOGIST)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:DAVID
Last Name:BLALOCK
Suffix:I
Gender:M
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:WAKE FOREST BAPTIST HEALTH MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-8207
Mailing Address - Fax:336-716-8868
Practice Address - Street 1:WAKE FOREST BAPTIST HEALTH MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-8207
Practice Address - Fax:336-716-8868
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist