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General NPI Number Information
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NPI Number | 1225347396
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Entity Type | Organization
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Legal Business Name | BLAYLOCK ANESTHESIA GROUP
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Dates
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Enumeration Date | 10/06/2010
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Last Update Date | 10/06/2010
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Provider Practice Location Address
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Address Line | 1905 DOCTORS HOSPITAL DR
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City | BRIDGEPORT
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State | TX
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Zip | 76426-2260
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Country | US
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Telephone | 940-683-0300
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Fax |
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Provider Business Mailing Address
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Address Line | 1905 DOCTORS HOSPITAL DR
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City | BRIDGEPORT
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State | TX
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Zip | 76426-2260
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Country | US
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Telephone | 940-683-0300
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Fax |
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | WINNIE C BLAYLOCK
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Credential | CRNA
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Telephone | 940-683-0300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 227712
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License Number State | TX
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