1790783454 NPI number — GARNET JEAN BLATCHFORD MD

Table of content: GARNET JEAN BLATCHFORD MD (NPI 1790783454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790783454 NPI number — GARNET JEAN BLATCHFORD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLATCHFORD
Provider First Name:
GARNET
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVIS
Provider Other First Name:
GARNET
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790783454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9850 NICHOLAS ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68114-2186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-343-1122
Provider Business Mailing Address Fax Number:
402-343-1177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9850 NICHOLAS ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68114-2186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-343-1122
Provider Business Practice Location Address Fax Number:
402-343-1177
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X , with the licence number:  17044 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47053395014 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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