Provider Demographics
NPI:1568825578
Name:BLUNCK, HALLIE SIMONE (MD)
Entity Type:Individual
Prefix:
First Name:HALLIE
Middle Name:SIMONE
Last Name:BLUNCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-0111
Mailing Address - Fax:
Practice Address - Street 1:1501 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2815
Practice Address - Country:US
Practice Address - Phone:970-874-7681
Practice Address - Fax:970-874-2254
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0064101207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine