Basic Information
| Provider Information | |||||||||
| NPI: | 1316930571 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WYNDAL K BLANKENSHIP MD PA | ||||||||
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| OtherOrganizationName: | WYNDAL K BLANKENSHIP MD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 S JOHN SIMS PKWY | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325801212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506786621 | ||||||||
| FaxNumber: | 8507290331 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 S JOHN SIMS PKWY | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325801212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506786621 | ||||||||
| FaxNumber: | 8507290331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 12/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | INS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8506786621 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 256934500 | 05 | FL | MEDICAID | 46862 | 01 | BC NUMBER | OTHER | N1099 | 01 | FL | EDI SENDER NUMBER | OTHER |