Provider Demographics
NPI:1861492191
Name:BLANKENSHIP, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:BLANKENSHIP
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:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-0919
Mailing Address - Country:US
Mailing Address - Phone:912-826-4057
Mailing Address - Fax:912-826-2853
Practice Address - Street 1:594 S COLUMBIA AVE
Practice Address - Street 2:STE 100
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-0919
Practice Address - Country:US
Practice Address - Phone:912-826-4057
Practice Address - Fax:912-826-2853
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043557208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACN8505OtherRR MEDICARE
GA00791557AMedicaid
GA02BDFSKMedicare ID - Type Unspecified
GACN8505OtherRR MEDICARE