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General NPI Number Information
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NPI Number | 1326353798
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Entity Type | Organization
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Legal Business Name | BLAYLOCK MEDICAL CLINIC PA
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Dates
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Enumeration Date | 08/10/2010
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Last Update Date | 08/31/2010
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Provider Practice Location Address
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Address Line | 130 E WALKER ST
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City | GREENVILLE
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State | MS
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Zip | 38701-4766
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Country | US
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Telephone | 662-332-7211
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Fax | 662-332-0442
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Provider Business Mailing Address
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Address Line | 130 E WALKER ST
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City | GREENVILLE
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State | MS
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Zip | 38701-4766
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Country | US
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Telephone | 662-332-7211
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Fax | 662-332-0442
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Authorized Official
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Title or Position | M.D.
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Name | DARRELL N BLAYLOCK
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Credential | M.D.
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Telephone | 662-332-7211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 04644
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License Number State | MS
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