Healthcare Provider Details

I. General information

NPI: 1003912601
Provider Name (Legal Business Name): MORRIS ALONZO BLOUNT JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19400 N CREEK DR
LYNWOOD IL
60411
US

IV. Provider business mailing address

421 W MELROSE ST APT 1A
CHICAGO IL
60657-3808
US

V. Phone/Fax

Practice location:
  • Phone: 708-985-3040
  • Fax:
Mailing address:
  • Phone: 773-248-1950
  • Fax: 773-248-0614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036098685
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: