Provider Demographics
NPI:1558585828
Name:PAUL BLISSARD
Entity Type:Organization
Organization Name:PAUL BLISSARD
Other - Org Name:PAUL K BLISSARD MD FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:KING
Authorized Official - Last Name:BLISSARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-443-2228
Mailing Address - Street 1:4310 JAMES CASEY ST
Mailing Address - Street 2:STE 1-C
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1251
Mailing Address - Country:US
Mailing Address - Phone:512-443-2228
Mailing Address - Fax:512-443-2227
Practice Address - Street 1:4310 JAMES CASEY ST
Practice Address - Street 2:STE1-C
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1251
Practice Address - Country:US
Practice Address - Phone:512-443-2228
Practice Address - Fax:512-443-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084120701OtherTPI NUMBER
TX86W800OtherBLUE CROSS RENDERING NO.
TX137945507Medicaid
TX137945510OtherEPSDT RENDERING NO.
TX00N25XOtherBLUE CROSS NO.
TX137945510OtherEPSDT RENDERING NO.
TX084120701OtherTPI NUMBER
TX137945507Medicaid