Blen D Blackwell, PA-C
Individual provider Active NPI Physician Assistant · Hattiesburg, MS
NPI 1811217409 · NPPES record last updated Aug 20, 2013
Key facts
- NPI
- 1811217409
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- PA00132 (MS)
- Practice address
- 3688 Veterans Memorial Dr.
Suite 200
Hattiesburg, MS 39401 - Phone
- (601) 554-7400
- Fax
- (601) 554-7499
- NPI assigned
- Jun 4, 2010
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 7
Hospital & facility affiliations 2
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 2010
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- FGH Trauma Surgery Clinic
Practice addresses (Care Compare)
6051 U S Hwy 49
Hattiesburg, MS 39401-7200
Phone (601) 288-2690
Hospital & facility affiliations
- Forrest General Hospital
- South Central Reg Med Ctr
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100722000117 | MS | Practitioner - Physician Assistant | 6103958475 | Reassigns benefits to 3 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA00132 | MS | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Forrest County General Hospital | Current |
Accepting new patients | |
| Southern Bone & Joint Specialists | Current |
Accepting new patients | |
| Forrest County General Hospital | Current |
Accepting new patients | |
| Forrest County General Hospital | Past | Accepting new patients |
Locations
1215 Highway 98 Byp
Columbia, MS 39429
Phone (601) 268-5070
6051 U S Highway 49
Hattiesburg, MS 39401
Phone (601) 288-2690
3688 Veterans Memorial Dr
Ste 200
Hattiesburg, MS 39401
Phone (601) 554-7451
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA00132 | MS | Yes |
Addresses
Primary practice location
3688 Veterans Memorial Dr.
Suite 200
Hattiesburg, MS 39401
Mailing address
3688 Veterans Memorial Dr.
Suite 200
Hattiesburg, MS 39401
Phone (601) 554-7400
Other providers in Hattiesburg, MS
- William Bryan Bishop III
- Imad Bitar
- Robin Bixler
- Donna Maria Black
- Blackwater Medical LLC
- Kory Blackwell
- George Joshua Blair
- Hayden Elise Blakeman
- Susan E Blakeney
- Monica V Blakley
All providers in Hattiesburg, MS · Physician Assistant in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 20, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.