Provider Demographics
NPI:1306845284
Name:BLANC, PETER L
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:L
Last Name:BLANC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MARY ST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1677
Mailing Address - Country:US
Mailing Address - Phone:812-424-8231
Mailing Address - Fax:812-435-8782
Practice Address - Street 1:520 MARY ST
Practice Address - Street 2:SUITE 520
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1677
Practice Address - Country:US
Practice Address - Phone:812-424-8231
Practice Address - Fax:812-435-8782
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058448A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64081748Medicaid
E38808Medicare UPIN
836320RMedicare ID - Type Unspecified