Provider Demographics
NPI:1306941505
Name:CHILDREN'S CLINIC LTD
Entity type:Organization
Organization Name:CHILDREN'S CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:BLALOCK JR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-595-0358
Mailing Address - Street 1:23 MANHATTAN SQUARE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666
Mailing Address - Country:US
Mailing Address - Phone:757-595-0358
Mailing Address - Fax:757-595-6745
Practice Address - Street 1:23 MANHATTAN SQUARE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666
Practice Address - Country:US
Practice Address - Phone:757-595-0358
Practice Address - Fax:757-595-6745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035213208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006729932Medicaid
VA006797059Medicaid
VA1467457697OtherNPI NUMBER
VA1639174436OtherNPI NUMBER
VA1699770826OtherNPI NUMBER
VA1972508778OtherNPI NUMBER
VA006716962Medicaid
VA1316942550OtherNPI NUMBER
VA006703828Medicaid
VA010043859Medicaid
VA1104821339OtherNPI NUMBER
VA1619972833OtherNPI NUMBER
VA006769187Medicaid
VA1891790028OtherNPI NUMBER
VAG57884Medicare UPIN
VA006769187Medicaid
VA006797059Medicaid
VA1699770826OtherNPI NUMBER
VA1104821339OtherNPI NUMBER
VA1619972833OtherNPI NUMBER