Healthcare Provider Details

I. General information

NPI: 1649262312
Provider Name (Legal Business Name): WILLIAM J BLACKLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 SULLIVAN RD
STATESVILLE NC
28677-3437
US

IV. Provider business mailing address

650 SIGNAL HILL DRIVE EXT PO BOX 1845
STATESVILLE NC
28625-4353
US

V. Phone/Fax

Practice location:
  • Phone: 704-924-9111
  • Fax:
Mailing address:
  • Phone: 704-873-4277
  • Fax: 704-873-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20527
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: