Basic Information
| Provider Information | |||||||||
| NPI: | 1417004359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLALOCK | ||||||||
| FirstName: | TULLY | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1137 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329021137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219529696 | ||||||||
| FaxNumber: | 3219527937 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 BARTON BLVD | ||||||||
| Address2: | UNIT C14 | ||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216395177 | ||||||||
| FaxNumber: | 3216394927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME26001 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002048700 | 05 | FL | MEDICAID |