Basic Information
| Provider Information | |||||||||
| NPI: | 1740282201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACHLY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 129 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461400129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686270 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Practice Location | |||||||||
| Address1: | 7375 W US HIGHWAY 52 | ||||||||
| Address2: | |||||||||
| City: | NEW PALESTINE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461638950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178614171 | ||||||||
| FaxNumber: | 3178615325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 12/08/2010 | ||||||||
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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 | 01046880A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000112800 | 01 | IN | ANTHEM PIN # | OTHER | 200311740 | 01 | IN | MEDICAID GROUP PIN # | OTHER | 5259508 | 01 | IN | AETNA PIN # | OTHER | 80156759 | 01 | IN | MEDICARE RAILROAD # | OTHER | 200156140 | 05 | IN | MEDICAID |