Individual
MR. MARCUS E BLACKSTONE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
404 SE MAIN ST, SIMPSONVILLE, SC 29681-2652
(864) 963-8002
(864) 963-2742
Mailing address
PO BOX 279, 404 SOUTHEAST MAIN ST, SIMPSONVILLE, SC 29681
(864) 963-8002
(864) 963-2742
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
18747
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
18747
STATE LICENSE #
SC
05
—
187470
—
SC
01
—
576007863095
BCBS
SC
01
—
P00446146
RR MEDICARE
SC
Enumeration date
08/11/2006
Last updated
06/19/2012
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