Basic Information
| Provider Information | |||||||||
| NPI: | 1790736643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCO | ||||||||
| FirstName: | RUPERTO | ||||||||
| MiddleName: | DIVINO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5838 METRO WAY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162495300 | ||||||||
| FaxNumber: | 6162495410 | ||||||||
| Practice Location | |||||||||
| Address1: | 5838 METRO WAY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162495300 | ||||||||
| FaxNumber: | 6162495410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301076807 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4619765 | 05 | MI | MEDICAID | 4878220 | 05 | MI | MEDICAID | 4619756 | 05 | MI | MEDICAID | 4877705 | 05 | MI | MEDICAID | 0P441950001 | 01 | MI | MEDICARE TYPE 1 | OTHER |