Basic Information
Provider Information | |||||||||
NPI: | 1942592613 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLANCHARD | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | STEVEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4150 DEPUTY BILL CANTRELL MEMORIAL RD | ||||||||
Address2: | STE. 300 | ||||||||
City: | CUMMING | ||||||||
State: | GA | ||||||||
PostalCode: | 30040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708868111 | ||||||||
FaxNumber: | 7702058539 | ||||||||
Practice Location | |||||||||
Address1: | 4150 DEPUTY BILL CANTRELL MEMORIAL RD. | ||||||||
Address2: | STE. 300 | ||||||||
City: | CUMMING | ||||||||
State: | GA | ||||||||
PostalCode: | 30040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708868111 | ||||||||
FaxNumber: | 7702058539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2011 | ||||||||
LastUpdateDate: | 08/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2016-00752 | NC | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207X00000X | 076441 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | Q52016 | 05 | SC |   | MEDICAID | 1942592613 | 05 | NC |   | MEDICAID |