Provider Demographics
NPI:1598862989
Name:CHRENKA, BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:CHRENKA
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 1:530 N. LAFAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1098
Mailing Address - Country:US
Mailing Address - Phone:574-234-4176
Mailing Address - Fax:574-234-1561
Practice Address - Street 1:530 N. LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1098
Practice Address - Country:US
Practice Address - Phone:574-234-4176
Practice Address - Fax:574-234-1561
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056525A207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF44037Medicare UPIN
IN738980UMedicare ID - Type UnspecifiedMEDICARE PROVIDER #