Provider Demographics
NPI:1881658029
Name:BLANCHARD, KEVIN L (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:CRNA
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 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:803-536-0998
Practice Address - Street 1:3000 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1442
Practice Address - Country:US
Practice Address - Phone:803-395-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1357367500000X
GARN181838367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA507903223BMedicaid
GA507903223DMedicaid
SCGP2825Medicaid
SCGP2825Medicaid
SC7386Medicare PIN
GA507903223BMedicaid