Provider Demographics
NPI:1932139953
Name:BLANC, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:BLANC
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 1:125 S PARK DR
Mailing Address - Street 2:STE H
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-5952
Mailing Address - Country:US
Mailing Address - Phone:325-641-8648
Mailing Address - Fax:325-643-2227
Practice Address - Street 1:3350 EXECUTIVE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6878
Practice Address - Country:US
Practice Address - Phone:325-245-4501
Practice Address - Fax:325-245-4008
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3583207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151420002Medicaid
TX151420003Medicaid
TX8U8633OtherBLUE CROSS
TX151420001Medicaid
TX151420001Medicaid
TX151420002Medicaid
TXE92095Medicare UPIN
TX8740B9Medicare PIN
TXP00370857Medicare PIN
TX8U8633OtherBLUE CROSS