MEDICARE: MR. JONATHAN BLACKMON IDC

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	246QM0706X	Medical Technologist
2	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1619916186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN BLACKMON IDC

Provider Business Mailing Address
First Line	:	881 USS JAMES MADISON RD
Second Line	:	NAVAL SUBMARINE SUPPORT CENTER MEDICAL DEPARTMENT
City	:	KINGS BAY
State	:	GA
Zip	:	31547-2531
Country	:	US
Telephone Number	:	912-573-2940
Fax Number	:

Provider Business Practice Location Address
First Line	:	603 WILD GRAPE DR
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-3619
Country	:	US
Telephone Number	:	912-573-2940
Fax Number	:

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	08/12/2021

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