Basic Information
Provider Information | |||||||||
NPI: | 1740280379 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLANCHARD | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | ELEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | III | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 CONCOURSE BLVD | ||||||||
Address2: | SUITE 190 | ||||||||
City: | GLEN ALLEN | ||||||||
State: | VA | ||||||||
PostalCode: | 23059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045494030 | ||||||||
FaxNumber: | 8045494032 | ||||||||
Practice Location | |||||||||
Address1: | 5421 PATTERSON AVE | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232262003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042852006 | ||||||||
FaxNumber: | 8042852799 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2005 | ||||||||
LastUpdateDate: | 07/26/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 0101031562 | VA | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 0300045 | 01 |   | UNITED HEALTHCARE | OTHER | 60194 | 01 |   | SOUTHERN HEALTH | OTHER | 070014692 | 01 |   | RAILROAD MEDICARE | OTHER | 5989396 | 05 | VA |   | MEDICAID | 533012 | 01 |   | AETNA | OTHER | 016023 | 01 |   | ANTHEM | OTHER |