Provider Demographics
NPI:1386715969
Name:BLACKWOOD, GERARD (DC)
Entity type:Individual
Prefix:DR
First Name:GERARD
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 DORCHESTER AVE # B
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-1327
Mailing Address - Country:US
Mailing Address - Phone:617-436-5454
Mailing Address - Fax:617-436-5667
Practice Address - Street 1:1504 DORCHESTER AVE # B
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1327
Practice Address - Country:US
Practice Address - Phone:617-436-5454
Practice Address - Fax:617-436-5667
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1561111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1613383Medicaid
MAAA25980OtherHARVARD PILGRIM PROVIDER#
MAY39215OtherBCBS OF MA PROVIDER NUMBE
MA1613383Medicaid