1497700223 NPI number — DR. KRIS M BLY DO

Table of content: DR. KRIS M BLY DO (NPI 1497700223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497700223 NPI number — DR. KRIS M BLY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLY
Provider First Name:
KRIS
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1497700223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2777 ENTERPRISE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32763-8310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-774-2550
Provider Business Mailing Address Fax Number:
386-774-5667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2777 ENTERPRISE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763-8310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-774-2550
Provider Business Practice Location Address Fax Number:
386-774-5667
Provider Enumeration Date:
05/23/2006

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: 208D00000X , with the licence number:  OS10451 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207PE0004X , with the licence number: OS10451 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02001471B . This is a "CSR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 17085 . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 02001471A . This is a "INDIANA LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0S10451 . This is a "FLORIDA LICENCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 108569700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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