1871955633 NPI number — LOGAN BLANKENSHIP MD

Table of content: LOGAN BLANKENSHIP MD (NPI 1871955633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871955633 NPI number — LOGAN BLANKENSHIP MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANKENSHIP
Provider First Name:
LOGAN
Provider Middle Name:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871955633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 LAKELAND HILLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33805-3065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-680-7000
Provider Business Mailing Address Fax Number:
866-264-8519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 N FLORIDA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33805-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-680-7243
Provider Business Practice Location Address Fax Number:
866-264-8519
Provider Enumeration Date:
03/22/2016

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: 207VX0201X , with the licence number:  ME160155 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 119298300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com