Provider Demographics
NPI:1255391413
Name:BLANTON, HERMAN MACK (MD)
Entity type:Individual
Prefix:DR
First Name:HERMAN
Middle Name:MACK
Last Name:BLANTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-7338
Mailing Address - Fax:812-450-2193
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1674
Practice Address - Country:US
Practice Address - Phone:812-450-7338
Practice Address - Fax:812-450-2193
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077468A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00466542OtherRR MEDICARE
TX8V4241OtherBCBS TX
TX033102705Medicaid
TX1255391413OtherSCOTT AND WHITE HEALTH PLAN
TX8G9716Medicare PIN
TXP00466542OtherRR MEDICARE
TX8V4241OtherBCBS TX