MEDICARE: BRIAN BLAISCH M.D.

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	208000000X	Pediatrics Physician	G64161	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G64161	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1184648909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN BLAISCH M.D.

Provider Business Mailing Address
First Line	:	2700 INTERNATIONAL BLVD
Second Line	:	SUITE 11
City	:	OAKLAND
State	:	CA
Zip	:	94601-1520
Country	:	US
Telephone Number	:	510-533-1248
Fax Number	:	510-533-1870

Provider Business Practice Location Address
First Line	:	2700 INTERNATIONAL BLVD
Second Line	:	SUITE 11
City	:	OAKLAND
State	:	CA
Zip	:	94601-1520
Country	:	US
Telephone Number	:	510-533-1248
Fax Number	:	510-533-1870

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/09/2007

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