Healthcare Provider Details

I. General information

NPI: 1245201573
Provider Name (Legal Business Name): MICHAEL ALDRED BLACKWELL III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 8TH ST SUITE 4
N WILKESBORO NC
28659-4167
US

IV. Provider business mailing address

408 8TH ST SUITE 4
N WILKESBORO NC
28659-4167
US

V. Phone/Fax

Practice location:
  • Phone: 336-667-7171
  • Fax: 336-667-1095
Mailing address:
  • Phone: 336-667-7171
  • Fax: 336-667-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number9500290
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: