Provider Demographics
NPI:1548208721
Name:BLIKKEN, WAYLAND G (MD)
Entity Type:Individual
Prefix:
First Name:WAYLAND
Middle Name:G
Last Name:BLIKKEN
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 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:1305 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2783
Practice Address - Country:US
Practice Address - Phone:270-827-0353
Practice Address - Fax:270-827-4966
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045943A207L00000X, 207LP2900X
KY24826207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64880461Medicaid
430048801OtherRAILROAD MEDICARE
IN200121900Medicaid
IN000000065510OtherBLUE SHIELD
IN000000065510OtherBLUE SHIELD
IN200121900Medicaid