Provider Demographics
NPI:1700926268
Name:MARK B. BLICK D.O., P.A.
Entity Type:Organization
Organization Name:MARK B. BLICK D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-850-7272
Mailing Address - Street 1:6565 WEST LOOP SOUTH
Mailing Address - Street 2:STE 300
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-3500
Mailing Address - Country:US
Mailing Address - Phone:713-850-7272
Mailing Address - Fax:713-877-0970
Practice Address - Street 1:6565 WEST LOOP SOUTH
Practice Address - Street 2:STE 300
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3500
Practice Address - Country:US
Practice Address - Phone:713-850-7272
Practice Address - Fax:713-877-0970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0014HWOtherBLUE CROSS BLUE SHIELD
TX900004448OtherMEDICARE RAILROAD
TX00450TMedicare PIN
TX900004448OtherMEDICARE RAILROAD