Provider Demographics
NPI:1376656751
Name:BLANCO, FERMIN (MD)
Entity Type:Individual
Prefix:
First Name:FERMIN
Middle Name:
Last Name:BLANCO
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:PO BOX 35100
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-5100
Mailing Address - Country:US
Mailing Address - Phone:406-238-2500
Mailing Address - Fax:
Practice Address - Street 1:2800 10TH AVE N
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0703
Practice Address - Country:US
Practice Address - Phone:406-238-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200751208000000X
MTMED-PHYS-LIC-194992080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1373796Medicaid
LAOTHOOOMedicare UPIN