Provider Demographics
NPI:1003815515
Name:BLANKENSHIP, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 WHARF ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-5937
Mailing Address - Country:US
Mailing Address - Phone:304-291-3627
Mailing Address - Fax:304-598-3630
Practice Address - Street 1:63 WHARF ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-5937
Practice Address - Country:US
Practice Address - Phone:304-291-3627
Practice Address - Fax:304-598-3630
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19121207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0047827000Medicaid
WVWV19121AOtherHEALTH PLAN
WV550783964002OtherMT STATE BCBS
WV0867416Medicare ID - Type Unspecified
WVWV19121AOtherHEALTH PLAN