MEDICARE: MARY M BLAND MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	18471	WV
2	207Q00000X	Family Medicine Physician	0101256886	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001737863	OTHER	WV	MS BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104800051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY M BLAND MD

Provider Business Mailing Address
First Line	:	PO BOX 7068
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23707-0068
Country	:	US
Telephone Number	:	757-967-8622
Fax Number	:	757-686-0541

Provider Business Practice Location Address
First Line	:	1168 FIRST COLONIAL RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2444
Country	:	US
Telephone Number	:	757-686-3508
Fax Number	:	757-686-0541

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	11/17/2014

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