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General NPI Number Information
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NPI Number | 1689193237
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Entity Type | Organization
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Legal Business Name | GIM BARRY BLACKSTON, MD, PA
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Dates
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Enumeration Date | 09/14/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 8 MEMORIAL MEDICAL CT STE 4
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City | GREENVILLE
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State | SC
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Zip | 29605-4400
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Country | US
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Telephone | 864-242-5678
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Fax | 864-242-5679
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Provider Business Mailing Address
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Address Line | 8 MEMORIAL MEDICAL CT STE 4
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City | GREENVILLE
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State | SC
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Zip | 29605-4400
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Country | US
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Telephone | 864-242-5678
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Fax | 864-242-5679
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. BARRY C BLACKSTON
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Credential | MD
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Telephone | 864-242-5678
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 16698
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License Number State | SC
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