Basic Information
Provider Information | |||||||||
NPI: | 1881943140 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLALOCK | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 S 8TH ST | ||||||||
Address2: | SUITE 480W | ||||||||
City: | MURRAY | ||||||||
State: | KY | ||||||||
PostalCode: | 420712400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707621792 | ||||||||
FaxNumber: | 2707621783 | ||||||||
Practice Location | |||||||||
Address1: | 300 S 8TH ST STE 284W | ||||||||
Address2: |   | ||||||||
City: | MURRAY | ||||||||
State: | KY | ||||||||
PostalCode: | 420712452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707615756 | ||||||||
FaxNumber: | 2707522856 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2012 | ||||||||
LastUpdateDate: | 07/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 49156 | KY | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 13861634 | 01 | KY | CAQH | OTHER |