Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 2012-0546 | NM |
Y | 207X00000X | Orthopaedic Surgeon | MD13206 | RI |
NPI | 1003033119 |
---|---|
Provider Name | Brad D. Blankenhorn |
First Address | Providence, RI 02901-1119 |
Second Address | East Providence, RI 02914-5375 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2007 |
Last Update Date | 14/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110087299A | MASSHEALTH (01) | RI |
BB81009 | (05) | RI |