Provider Demographics
NPI:1902162928
Name:OCEAN ISLE BEACH FAMILY MEDICINE. PC
Entity Type:Organization
Organization Name:OCEAN ISLE BEACH FAMILY MEDICINE. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLIZZARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:910-575-5004
Mailing Address - Street 1:120 CAUSEWAY DR STE 3
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-7581
Mailing Address - Country:US
Mailing Address - Phone:910-575-5004
Mailing Address - Fax:855-575-0700
Practice Address - Street 1:120 CAUSEWAY DR STE 3
Practice Address - Street 2:
Practice Address - City:OCEAN ISLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28469-7581
Practice Address - Country:US
Practice Address - Phone:910-575-5004
Practice Address - Fax:855-575-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC181477261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1902162928OtherNPI
NC5920193Medicaid
NCB502OtherMEDICARE PTAN
34D1040435OtherCLIA
NC5920193Medicaid