Basic Information
| Provider Information | |||||||||
| NPI: | 1073576856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEW | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLEW | ||||||||
| OtherFirstName: | R. | ||||||||
| OtherMiddleName: | MARK | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6567 E CARONDELET DR | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857102119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208856701 | ||||||||
| FaxNumber: | 5208859037 | ||||||||
| Practice Location | |||||||||
| Address1: | 6567 E CARONDELET DR | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857102156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208856701 | ||||||||
| FaxNumber: | 5208859037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 01/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 11757 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 11757 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XX0004X | 11757 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | 11757 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 224551-01 | 05 | AZ | MEDICAID |