Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 4247-012 | WI |
N | 111NR0200X | Radiology | 038-011886 | IL |
N | 213ER0200X | Radiology | 038-011886 | IL |
N | 111NR0400X | Rehabilitation Chiropractor | 038-011886 | IL |
Y | 2081P2900X | Pain Medicine | 038-011886 | IL |
NPI | 1518029230 |
---|---|
Provider Name | Dr. Emmett Andrew Blahnik |
First Address | Rockford, IL 61107-1819 |
Second Address | Rockford, IL 61107-6819 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2006 |
Last Update Date | 02/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000015023 | MEDICARE PTAN (01) | WI |
V11-004 | (02) | WI |