Basic Information
| Provider Information | |||||||||
| NPI: | 1982662870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLONDHEIM | ||||||||
| FirstName: | IRA | ||||||||
| MiddleName: | LANE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 CRESCENT CENTRE DR STE 600 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370677286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153731350 | ||||||||
| FaxNumber: | 6152219054 | ||||||||
| Practice Location | |||||||||
| Address1: | 6971 EASTCHASE LOOP | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361176876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347216500 | ||||||||
| FaxNumber: | 3347216501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 225100000X | PTH3183 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 515-20068 | 01 | AL | BCBS NUMBER | OTHER |