Basic Information
Provider Information | |||||||||
NPI: | 1003815515 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLANKENSHIP | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 63 WHARF ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265015937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042913627 | ||||||||
FaxNumber: | 3045983630 | ||||||||
Practice Location | |||||||||
Address1: | 63 WHARF ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265015937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042913627 | ||||||||
FaxNumber: | 3045983630 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 19121 | WV | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0047827000 | 05 | WV |   | MEDICAID | WV19121A | 01 | WV | HEALTH PLAN | OTHER | 550783964002 | 01 | WV | MT STATE BCBS | OTHER |