1417905084 NPI number — MR. CRAIG BLANDA MPT, CERT.MDT

Table of content: MR. CRAIG BLANDA MPT, CERT.MDT (NPI 1417905084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417905084 NPI number — MR. CRAIG BLANDA MPT, CERT.MDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANDA
Provider First Name:
CRAIG
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MPT, CERT.MDT
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:
1417905084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 BECKETT RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LOGAN TOWNSHIP
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08085-1732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-467-3421
Provider Business Mailing Address Fax Number:
856-467-5731

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 BECKETT RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LOGAN TWP
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08085-1732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-467-3421
Provider Business Practice Location Address Fax Number:
856-467-5731
Provider Enumeration Date:
05/05/2006

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: 225100000X , with the licence number:  QA08484 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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