Basic Information
| Provider Information | |||||||||
| NPI: | 1780689794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANNETT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1503 LANSDOWNE AVE | ||||||||
| Address2: | STE 3001 | ||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105864100 | ||||||||
| FaxNumber: | 6105864114 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 LANSDOWNE AVE | ||||||||
| Address2: | STE 3001 | ||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105864100 | ||||||||
| FaxNumber: | 6105864114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207RC0000X | MD019872E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0007457350008 | 05 | PA | MEDICAID |