Basic Information
Provider Information | |||||||||
NPI: | 1902872708 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLONDEAU | ||||||||
FirstName: | BENOIT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD MBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554254516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 401 PHALEN BLVD | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551305302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512547980 | ||||||||
FaxNumber: | 6512547969 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2006 | ||||||||
LastUpdateDate: | 06/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086H0002X | MD2019-0810 | NM | N |   | Allopathic & Osteopathic Physicians | Surgery | Hospice and Palliative Medicine | 2086S0102X | MD2019-0810 | NM | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | MD2019-0810 | NM | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 69252 | MN | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.