1598785834 NPI number — JASON H BLASENAK DO

Table of content: JASON H BLASENAK DO (NPI 1598785834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598785834 NPI number — JASON H BLASENAK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLASENAK
Provider First Name:
JASON
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1598785834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 ENTERPRISE BLVD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-6300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-454-0888
Provider Business Mailing Address Fax Number:
864-454-1130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 GROVE RD
Provider Second Line Business Practice Location Address:
GMH ER ADMINISTRATION
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605-5611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-455-6372
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2006

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: 207P00000X , with the licence number:  OS18227 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 22902 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 978 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 57-6007863 . This is a "BCBS OF SOUTH CAROLINA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 57-6007863 . This is a "TRICARE-CHAMPUS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 009788 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00379730 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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