Provider Demographics
NPI:1578568572
Name:BLICKENSDERFER, SCOTT ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
Last Name:BLICKENSDERFER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:STE 230
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-251-2100
Mailing Address - Fax:574-251-2151
Practice Address - Street 1:6301 UNIVERSITY COMMONS
Practice Address - Street 2:STE 350
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1571
Practice Address - Country:US
Practice Address - Phone:574-234-4100
Practice Address - Fax:574-282-1739
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02001398A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000234054OtherANTHEM
IN264180VOtherMEDICARE PTAN
IN100093110Medicaid
IN100093110Medicaid