Provider Demographics
NPI:1396798716
Name:BLESTEL, GEORGE AMBROSE JR (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:AMBROSE
Last Name:BLESTEL
Suffix:JR
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:
Practice Address - Street 1:1690 SKYLYN DR
Practice Address - Street 2:SUITE 140
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1022
Practice Address - Country:US
Practice Address - Phone:864-591-1664
Practice Address - Fax:864-577-0620
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12790208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC127909Medicaid
SCP00682386OtherRR MEDICARE
SCE048457951Medicare PIN
SC127909Medicaid
SCE048453640Medicare PIN