Basic Information
| Provider Information | |||||||||
| NPI: | 1962480939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | OSCAR | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD | ||||||||
| Address2: | ATTN FORSYTH MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772436 | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 PINEYWOOD RD | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273603438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364758121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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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 | 21625 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | AB7656272 | 01 | FEDERAL DEA | OTHER | 8916092 | 05 | NC | MEDICAID |