Provider Demographics
NPI:1740332600
Name:BLANZY, EDWARD A (DO)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:BLANZY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-7960
Practice Address - Street 1:19117 ALLEN RD STE A
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1066
Practice Address - Country:US
Practice Address - Phone:734-676-4040
Practice Address - Fax:734-676-9897
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101010788208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G20960OtherHEALTH ALLIANCE PLAN
M033558OtherCHAMPUS
P125599OtherCARE CHOICES
C5605OtherM-CARE
MI3458203525OtherBLUE CROSS BLUE SHIELD
G20960Medicare UPIN
MI3458203525OtherBLUE CROSS BLUE SHIELD