MEDICARE: JESSE AYCOCK BLACKMAN M.D.

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	207Q00000X	Family Medicine Physician	18609	NC

General Provider Information

NPI Number	:	1811936826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE AYCOCK BLACKMAN M.D.

Provider Business Mailing Address
First Line	:	5413 US HIGHWAY 117 N
Second Line	:
City	:	PIKEVILLE
State	:	NC
Zip	:	27863-9445
Country	:	US
Telephone Number	:	919-242-5271
Fax Number	:	919-242-5096

Provider Business Practice Location Address
First Line	:	5413 US HIGHWAY 117 N
Second Line	:
City	:	PIKEVILLE
State	:	NC
Zip	:	27863-9445
Country	:	US
Telephone Number	:	919-242-5271
Fax Number	:	919-242-5096

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	07/08/2007

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