Provider Demographics
NPI:1376518795
Name:BLITCH, EDWIN LEO IV (DPM)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:LEO
Last Name:BLITCH
Suffix:IV
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9313 MEDICAL PLAZA DR
Mailing Address - Street 2:301
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9155
Mailing Address - Country:US
Mailing Address - Phone:843-553-2909
Mailing Address - Fax:843-553-4684
Practice Address - Street 1:9313 MEDICAL PLAZA DR
Practice Address - Street 2:301
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9155
Practice Address - Country:US
Practice Address - Phone:843-553-2909
Practice Address - Fax:843-553-4684
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC134213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD1340Medicaid
SCY37255Medicare UPIN