Provider Demographics
NPI:1245403120
Name:JEFFREY G BLANK DPM LLC
Entity Type:Organization
Organization Name:JEFFREY G BLANK DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:312-642-9311
Mailing Address - Street 1:55 W CHESTNUT ST
Mailing Address - Street 2:1005
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 W CHESTNUT ST
Practice Address - Street 2:1005
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-3347
Practice Address - Country:US
Practice Address - Phone:312-642-9311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2618550001Medicare NSC
ILU36164Medicare UPIN