Provider Demographics
NPI:1255642815
Name:PAINE, PHILIP BLANCHARD (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:BLANCHARD
Last Name:PAINE
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 1:3390 TAMIAMI TRL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3390 TAMIAMI TRL
Practice Address - Street 2:SUITE 204
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8157
Practice Address - Country:US
Practice Address - Phone:941-391-5496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24661207R00000X
FLME 116677207R00000X
LAMD .206193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2111345Medicaid