Provider Demographics
NPI:1396736070
Name:BLANK, HAL H (CSA OPAC)
Entity type:Individual
Prefix:MR
First Name:HAL
Middle Name:H
Last Name:BLANK
Suffix:
Gender:M
Credentials:CSA OPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7073 STONECREEK DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-7923
Mailing Address - Country:US
Mailing Address - Phone:317-838-8999
Mailing Address - Fax:317-838-8999
Practice Address - Street 1:7073 STONECREEK DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-7923
Practice Address - Country:US
Practice Address - Phone:317-838-8999
Practice Address - Fax:317-838-8999
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000097174400000X
KYSA081246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No174400000XOther Service ProvidersSpecialist