Provider Demographics
NPI:1295808426
Name:BLANZY CLINIC
Entity type:Organization
Organization Name:BLANZY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLANZY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-285-0677
Mailing Address - Street 1:14319 DIX TOLEDO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2506
Mailing Address - Country:US
Mailing Address - Phone:734-285-0677
Mailing Address - Fax:734-285-3574
Practice Address - Street 1:14319 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2506
Practice Address - Country:US
Practice Address - Phone:734-285-0677
Practice Address - Fax:734-285-3574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164462347OtherINDIVIDUAL NPI #
MI1629017207OtherNPI INDIVIUAL #
MI1134169444OtherNPI INDIVIDUAL NUMBER
MI1710926399OtherINDIVIDUAL NPI #
MIOH24773Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER