Provider Demographics
NPI:1235132598
Name:BLATY, LAWRENCE R (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:R
Last Name:BLATY
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 1:43555 DALCOMA DR
Mailing Address - Street 2:STE 4
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6310
Mailing Address - Country:US
Mailing Address - Phone:586-228-2882
Mailing Address - Fax:586-463-7152
Practice Address - Street 1:43555 DALCOMA DR
Practice Address - Street 2:STE 4
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-6310
Practice Address - Country:US
Practice Address - Phone:586-228-2882
Practice Address - Fax:586-463-7152
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407526208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2505006321OtherBCN
MI126951OtherCARE CHOICES-PREFERRED
MIC6815OtherM-CARE
25009724OtherRAILROAD MEDICARE
MI1792650Medicaid
MILB407526OtherBCBSM
MIOE06114Medicare ID - Type Unspecified
MIC6815OtherM-CARE