1558585828 NPI number — PAUL BLISSARD

Table of content: (NPI 1558585828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558585828 NPI number — PAUL BLISSARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL BLISSARD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAUL K BLISSARD MD FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
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:
1558585828
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4310 JAMES CASEY ST
Provider Second Line Business Mailing Address:
STE 1-C
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78745-1251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-443-2228
Provider Business Mailing Address Fax Number:
512-443-2227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4310 JAMES CASEY ST
Provider Second Line Business Practice Location Address:
STE1-C
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78745-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-443-2228
Provider Business Practice Location Address Fax Number:
512-443-2227
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLISSARD
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
KING
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
512-443-2228

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  F6453 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 084120701 . This is a "TPI NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 86W800 . This is a "BLUE CROSS RENDERING NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 137945507 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 137945510 . This is a "EPSDT RENDERING NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00N25X . This is a "BLUE CROSS NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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