Provider Demographics
NPI:1013969765
Name:BLANK, SETH D (MD)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:D
Last Name:BLANK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:144 STATE ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3776
Mailing Address - Country:US
Mailing Address - Phone:207-879-3120
Mailing Address - Fax:207-879-3127
Practice Address - Street 1:144 STATE ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3776
Practice Address - Country:US
Practice Address - Phone:207-879-3120
Practice Address - Fax:207-879-3127
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD13305208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME299350099Medicaid
ME299350099Medicaid
MEMM431702Medicare PIN
MEMM4317Medicare PIN
MEF29018Medicare UPIN
MEP01050854Medicare PIN