Provider Demographics
NPI:1376698589
Name:BLANKEN PODIATRY GROUP
Entity type:Organization
Organization Name:BLANKEN PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:SELBY
Authorized Official - Last Name:BLANKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-592-0505
Mailing Address - Street 1:10313 GEORGIA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-5006
Mailing Address - Country:US
Mailing Address - Phone:301-592-0505
Mailing Address - Fax:301-592-0503
Practice Address - Street 1:10313 GEORGIA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5006
Practice Address - Country:US
Practice Address - Phone:301-592-0505
Practice Address - Fax:301-592-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01135213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD450798300Medicaid
DC025912100Medicaid
MDKDK7BLOtherCAREFIRST
MD88280001OtherBCBS
MD0927060001Medicare NSC
MDKDK7BLOtherCAREFIRST