Provider Demographics
NPI:1396725768
Name:BLECHLE, KEVIN W (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:W
Last Name:BLECHLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5359 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2738
Mailing Address - Country:US
Mailing Address - Phone:563-742-5900
Mailing Address - Fax:563-742-5905
Practice Address - Street 1:5359 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2738
Practice Address - Country:US
Practice Address - Phone:563-742-5900
Practice Address - Fax:563-742-5905
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02836207Q00000X
IL036-102383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-102383Medicaid
ILP00055265OtherRR MEDICARE
IA1396725768Medicaid
IA719260342Medicare PIN
IL200715026Medicare PIN
F79291Medicare UPIN
IAI14401Medicare PIN
ILK01305Medicare PIN