Provider Demographics
NPI:1316948185
Name:BLACKSTON, BARRY C (MD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:C
Last Name:BLACKSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8 MEMORIAL MEDICAL CT
Mailing Address - Street 2:STE 4
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4400
Mailing Address - Country:US
Mailing Address - Phone:864-242-5678
Mailing Address - Fax:864-242-5679
Practice Address - Street 1:8 MEMORIAL MEDICAL CT
Practice Address - Street 2:STE 4
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4400
Practice Address - Country:US
Practice Address - Phone:864-242-5678
Practice Address - Fax:864-242-5679
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC16698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3048Medicaid
SCGO27900281Medicare ID - Type Unspecified
SCGP3048Medicaid