Provider Demographics
NPI:1699759381
Name:JOHN B BLALOCK JR MD PC
Entity type:Organization
Organization Name:JOHN B BLALOCK JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT JOHN B BLALOCK JR MD PC
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:205-933-7301
Mailing Address - Street 1:2660 10TH AVE S
Mailing Address - Street 2:STE 238
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1605
Mailing Address - Country:US
Mailing Address - Phone:205-933-7301
Mailing Address - Fax:205-933-7304
Practice Address - Street 1:2660 10TH AVE S
Practice Address - Street 2:STE 238
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1605
Practice Address - Country:US
Practice Address - Phone:205-933-7301
Practice Address - Fax:205-933-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9169208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL87171OtherBC BS OF AL
AL00087171Medicaid
AL000087171Medicare ID - Type Unspecified
AL87171OtherBC BS OF AL
AL000087171Medicare PIN