Basic Information
| Provider Information | |||||||||
| NPI: | 1679558662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCHARD-BURCH | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3719 DAUPHIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513439090 | ||||||||
| FaxNumber: | 2513801015 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MEMORIAL HOSPITAL DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513439090 | ||||||||
| FaxNumber: | 2513801015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 00026347 | AL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 051556022 | 05 | AL | MEDICAID |