Provider Demographics
NPI:1043274616
Name:BLANCHARD, BERTHA J (MD)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:J
Last Name:BLANCHARD
Suffix:
Gender:F
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:PO BOX 15548
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-5548
Mailing Address - Country:US
Mailing Address - Phone:601-268-5222
Mailing Address - Fax:601-296-3508
Practice Address - Street 1:105 ASBURY CIR
Practice Address - Street 2:SUITE A
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1302
Practice Address - Country:US
Practice Address - Phone:601-268-5222
Practice Address - Fax:601-296-3508
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS115012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00111298Medicaid
C67465Medicare UPIN