Healthcare Provider Details

I. General information

NPI: 1225082852
Provider Name (Legal Business Name): WILLIAM ALLEN BLALOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

IV. Provider business mailing address

65 CONIFER CIR
AUGUSTA GA
30909-4508
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-2791
  • Fax:
Mailing address:
  • Phone: 706-737-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number29588
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: