Basic Information
| Provider Information | |||||||||
| NPI: | 1366887002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | OLIVIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 547 LEGRAND PL | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361061825 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352290001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057264472 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | T34014 | AL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.