1164440368 NPI number — TIMOTHY BLANKENSHIP O.D.

Table of content: TIMOTHY BLANKENSHIP O.D. (NPI 1164440368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164440368 NPI number — TIMOTHY BLANKENSHIP O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANKENSHIP
Provider First Name:
TIMOTHY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1164440368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 W DEYOUNG ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-4437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-993-5686
Provider Business Mailing Address Fax Number:
618-997-6250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2511 N WESTWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-5866
Provider Business Practice Location Address Fax Number:
573-686-0425
Provider Enumeration Date:
07/17/2006

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: 152W00000X , with the licence number:  2006018048 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00434357 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 211780 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0814870017 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0814870002 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: MO8048 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0814870015 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 127205 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 310865506 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com