Provider Demographics
NPI:1548328776
Name:W, STANFORD BLALOCK, MD, PLC
Entity type:Organization
Organization Name:W, STANFORD BLALOCK, MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:STANFORD
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-906-9860
Mailing Address - Street 1:279 CLEAR SKY CT UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5653
Mailing Address - Country:US
Mailing Address - Phone:931-906-9860
Mailing Address - Fax:931-906-9858
Practice Address - Street 1:279 CLEAR SKY CT UNIT 3
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5653
Practice Address - Country:US
Practice Address - Phone:931-906-9860
Practice Address - Fax:931-906-9858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16583174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty