Basic Information
| Provider Information | |||||||||
| NPI: | 1366491342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOUIN | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 PATEWOOD DR | ||||||||
| Address2: | SUITE A350 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644545110 | ||||||||
| FaxNumber: | 8644545141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 8372 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0008X | 8372 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 4304559 | 01 | SC | AETNA | OTHER | 57-6007863080 | 01 | SC | BCBS OF SC | OTHER | 083723 | 05 | SC | MEDICAID | 57-6007863037 | 01 | SC | BLUE CHOICE OF SC | OTHER | 1385497 | 01 | SC | CIGNA | OTHER |