Provider Demographics
NPI:1700075603
Name:DUNKIN-BLANTON HEALTH CENTER
Entity Type:Organization
Organization Name:DUNKIN-BLANTON HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:DUNKIN-BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-544-5698
Mailing Address - Street 1:211 N WILSON DR
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45693-1562
Mailing Address - Country:US
Mailing Address - Phone:937-544-5698
Mailing Address - Fax:937-544-1708
Practice Address - Street 1:211 N WILSON DR
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-1562
Practice Address - Country:US
Practice Address - Phone:937-544-5698
Practice Address - Fax:937-544-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050128D174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0558570Medicaid
OH300016OtherAMERIGROUP
OH=========27OtherCARESOURCE
OHA15858Medicare UPIN