Healthcare Provider Details

I. General information

NPI: 1619708914
Provider Name (Legal Business Name): BLACKWELL PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12008 CHERRY HILL RD
SILVER SPRING MD
20904-1985
US

IV. Provider business mailing address

820 W DIAMOND AVE STE 500
GAITHERSBURG MD
20878-1469
US

V. Phone/Fax

Practice location:
  • Phone: 301-762-8155
  • Fax:
Mailing address:
  • Phone: 301-315-3826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAMELA MCCLAIN
Title or Position: VP MANAGED CARE
Credential:
Phone: 301-315-3430