Provider Demographics
NPI:1841429909
Name:BLANKENSHIP INTERNAL MEDICINE, L.L.C.
Entity Type:Organization
Organization Name:BLANKENSHIP INTERNAL MEDICINE, L.L.C.
Other - Org Name:HAROLD BLANKENSHIP, D.O., F.A.C.O.I.
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-782-2125
Mailing Address - Street 1:1905 W 32ND ST
Mailing Address - Street 2:STE. 407
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1529
Mailing Address - Country:US
Mailing Address - Phone:417-782-2125
Mailing Address - Fax:417-782-2145
Practice Address - Street 1:1905 W 32ND ST
Practice Address - Street 2:STE. 407
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1529
Practice Address - Country:US
Practice Address - Phone:417-782-2125
Practice Address - Fax:417-782-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005009945207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100183010AMedicaid
KS200312050AMedicaid
197311OtherANTHEM
MO207291402Medicaid
P00215074OtherRR MEDICARE
OK100183010AMedicaid
MO931193658Medicare PIN