Basic Information
| Provider Information | |||||||||
| NPI: | 1508975632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAND | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453389503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379622618 | ||||||||
| FaxNumber: | 9379624971 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453389503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379622618 | ||||||||
| FaxNumber: | 9379624971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35073056B | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2061174 | 05 | OH | MEDICAID |