Provider Demographics
NPI:1619902293
Name:BLANK, STEPHEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:BLANK
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 1:3525 PIEDMONT RD NE
Mailing Address - Street 2:BLDG 7-601
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1578
Mailing Address - Country:US
Mailing Address - Phone:404-842-5400
Mailing Address - Fax:
Practice Address - Street 1:755 MOUNT VERNON HWY NE
Practice Address - Street 2:#330
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4274
Practice Address - Country:US
Practice Address - Phone:404-256-2277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019640207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000188174CMedicaid
160045559Medicare PIN
GA000188174CMedicaid
GA16BDTMQMedicare PIN