Basic Information
| Provider Information | |||||||||
| NPI: | 1891879268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOD | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19420 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177880706 | ||||||||
| FaxNumber: | 2177887032 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 N RUTLEDGE ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627026700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177880706 | ||||||||
| FaxNumber: | 2177887032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363AM0700X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.