Provider Demographics
NPI:1790052082
Name:DAVID W BLODGETT MD PLLC
Entity Type:Organization
Organization Name:DAVID W BLODGETT MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLODGETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-761-5573
Mailing Address - Street 1:839 RANDALL CT
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1368
Mailing Address - Country:US
Mailing Address - Phone:248-761-5573
Mailing Address - Fax:
Practice Address - Street 1:375 BARCLAY DR.
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-852-3636
Practice Address - Fax:248-852-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075561174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI005491912Medicaid