1881767960 NPI number — MARYJANE BLANCHFIELD

Table of content: MARYJANE BLANCHFIELD (NPI 1881767960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881767960 NPI number — MARYJANE BLANCHFIELD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANCHFIELD
Provider First Name:
MARYJANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1881767960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7535 54TH ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58362-9567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 4TH ST NW
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
DEVILS LAKE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58301-2960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-662-6776
Provider Business Practice Location Address Fax Number:
701-662-6889
Provider Enumeration Date:
11/16/2006

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: 101Y00000X , with the licence number:  603 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 22354 . This is a "BCBSND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 19153 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 58301-A002 . This is a "TRIWEST" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 62-56618 . This is a "MEDICA UBH" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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