Provider Demographics
NPI:1396782488
Name:BLALOCK, CLYDE P (MD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:P
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 49009
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0001
Mailing Address - Country:US
Mailing Address - Phone:864-223-3070
Mailing Address - Fax:864-223-1396
Practice Address - Street 1:955 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5441
Practice Address - Country:US
Practice Address - Phone:843-522-5130
Practice Address - Fax:843-522-5538
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC210362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG24901Medicaid
SCG24901Medicaid