MEDICARE: JEANA ERA-ELLEN BLALOCK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	33988	AL

General Provider Information

NPI Number	:	1730524414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANA ERA-ELLEN BLALOCK MD

Provider Business Mailing Address
First Line	:	301 GOVERNORS DR SW
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35801-5123
Country	:	US
Telephone Number	:	256-551-4631
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 MEMORIAL PKWY SW
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35801-5318
Country	:	US
Telephone Number	:	256-536-4700
Fax Number	:	256-536-4117

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2013
Last Update Date	:	07/03/2024

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