1932221058 NPI number — DR. CHERYL RAE BLANK PH.D.

Table of content: DR. CHERYL RAE BLANK PH.D. (NPI 1932221058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932221058 NPI number — DR. CHERYL RAE BLANK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANK
Provider First Name:
CHERYL
Provider Middle Name:
RAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1932221058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4744 ITANA CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59715-9330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-579-2427
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 W KAGY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-587-7468
Provider Business Practice Location Address Fax Number:
406-587-4520
Provider Enumeration Date:
04/06/2007

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: 101YA0400X , with the licence number:  457 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 202 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51011 . This is a "BLUE CROSS - MSU" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0000490807 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 264349 . This is a "NEW WEST" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 86-1155463 . This is a "TRI CARE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 52820 . This is a "BLUE CROSS - PRIVATE PRAC" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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