Basic Information
| Provider Information | |||||||||
| NPI: | 1114929361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLASDELL | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3300 HIGH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237073321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576735680 | ||||||||
| FaxNumber: | 7573970236 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 HIGH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237073321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576735680 | ||||||||
| FaxNumber: | 7573970236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 02/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101039494 | VA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 006498507 | 05 | VA | MEDICAID |