MEDICARE: MR. MICHAEL ALDRED BLACKWELL III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	9500290	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0297M	OTHER	NC	BCBS
2	07-07548	OTHER	NC	UNITED HEALTHCARE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245201573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL ALDRED BLACKWELL III MD

Provider Business Mailing Address
First Line	:	408 8TH ST
Second Line	:	SUITE 4
City	:	N WILKESBORO
State	:	NC
Zip	:	28659-4167
Country	:	US
Telephone Number	:	336-667-7171
Fax Number	:	336-667-1095

Provider Business Practice Location Address
First Line	:	408 8TH ST
Second Line	:	SUITE 4
City	:	N WILKESBORO
State	:	NC
Zip	:	28659-4167
Country	:	US
Telephone Number	:	336-667-7171
Fax Number	:	336-667-1095

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	05/20/2015

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