Basic Information
| Provider Information | |||||||||
| NPI: | 1578576674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKLEY | ||||||||
| FirstName: | SHEM | ||||||||
| MiddleName: | KEARNEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9735 KINCEY AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280789118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044142870 | ||||||||
| FaxNumber: | 7044142860 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281501800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044822011 | ||||||||
| FaxNumber: | 7044840303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 32340 | NC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 340013360 | 01 | NC | RR MEDICARE | OTHER | 32340 | 01 | NC | NC MEDICAL LICENSE # | OTHER | 230126 | 01 | NC | MEDICARE PTAN | OTHER |