Basic Information
| Provider Information | |||||||||
| NPI: | 1396725768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLECHLE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5359 EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528072738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5637425900 | ||||||||
| FaxNumber: | 5637425905 | ||||||||
| Practice Location | |||||||||
| Address1: | 5359 EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528072738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5637425900 | ||||||||
| FaxNumber: | 5637425905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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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 | 207Q00000X | 02836 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-102383 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-102383 | 05 | IL | MEDICAID | P00055265 | 01 | IL | RR MEDICARE | OTHER | 1396725768 | 05 | IA | MEDICAID |