Basic Information
| Provider Information | |||||||||
| NPI: | 1396724472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLACKWELL EYE ASSOCIATES, P. A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1268 EBENEZER RD | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297322341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033272001 | ||||||||
| FaxNumber: | 8033279843 | ||||||||
| Practice Location | |||||||||
| Address1: | 1268 EBENEZER RD | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297322341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033272001 | ||||||||
| FaxNumber: | 8033279843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | BLACKWELL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | BRITT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8033272001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 08220 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | DA9891 | 05 | SC | MEDICAID |