Basic Information
| Provider Information | |||||||||
| NPI: | 1093930208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWOOD | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | LANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2835 BRANDYWINE RD | ||||||||
| Address2: | #300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303415540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562593 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1062 FORSYTH ST | ||||||||
| Address2: | SUITE 3A | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312018637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787434622 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 062657 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
No ID Information.