Provider Demographics
NPI:1538279609
Name:ANDERSEN, BLAINE P (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:P
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1300 N 500 E
Mailing Address - Street 2:#260
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2408
Mailing Address - Country:US
Mailing Address - Phone:435-753-3400
Mailing Address - Fax:435-787-8887
Practice Address - Street 1:1300 N 500 E
Practice Address - Street 2:#260
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2408
Practice Address - Country:US
Practice Address - Phone:435-753-3400
Practice Address - Fax:435-787-8887
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1788161205208200000X
UT17881689052082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003052200Medicaid
ID003052200Medicaid
UT$$$$$$$$$002Medicaid