Healthcare Provider Details

I. General information

NPI: 1811973423
Provider Name (Legal Business Name): WILLIAM BLAYLOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 BRAEBURN CIR
SALEM VA
24153-7388
US

IV. Provider business mailing address

1930 BRAEBURN CIR
SALEM VA
24153-7388
US

V. Phone/Fax

Practice location:
  • Phone: 540-444-5600
  • Fax: 540-444-5617
Mailing address:
  • Phone: 540-444-5600
  • Fax: 540-444-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number0101018545
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: