1992881122 NPI number — MICHAEL W BLANEY MD

Table of content: MICHAEL W BLANEY MD (NPI 1992881122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992881122 NPI number — MICHAEL W BLANEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANEY
Provider First Name:
MICHAEL
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1992881122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 CENTRAL AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-738-3359
Provider Business Mailing Address Fax Number:
706-738-0565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3830 WASHINGTON RD STE 17
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINEZ
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30907-5080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-922-0440
Provider Business Practice Location Address Fax Number:
706-922-0441
Provider Enumeration Date:
10/31/2006

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: 208600000X , with the licence number:  40614 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G40614 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000906727C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".