Basic Information
| Provider Information | |||||||||
| NPI: | 1467491233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAMES M BLAYLOCK MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269086 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052313857 | ||||||||
| FaxNumber: | 4059427743 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 NW 9TH ST | ||||||||
| Address2: | SUITE 6110 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052726909 | ||||||||
| FaxNumber: | 4052313723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 06/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | BLALOCK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | MATTISON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4052726909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 12285 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 200080450A | 05 | OK | MEDICAID | DF0246 | 01 | OK | GROUP RAILROAD MCARE | OTHER |