Individual
KORY BLACKWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
5192 OLD HIGHWAY 11 STE 2, HATTIESBURG, MS 39402-6222
(601) 268-0929
(601) 261-0508
Mailing address
415 SOUTH 28TH AVENUE, HATTIESBURG, MS 39401
(601) 579-5463
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
24444
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
08076764
—
MS
Enumeration date
04/24/2014
Last updated
01/07/2021
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