MEDICARE: DR. MARK EDWIN DEBLOIS 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	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician	101036512	VA
2	207X00000X	Orthopaedic Surgery Physician	0101036512	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
15	200019198	OTHER	VA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	061547	OTHER	VA	ANTHEM HEALTHKEEPERS PLUS
2	061547	OTHER	VA	ANTHEM
3	540885859	OTHER	VA	C&O EMPLOYEES HOSP ASSO
4	540885859	OTHER	VA	FARA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	2138265	OTHER	VA	UNITED HEALTH CARE MAMSI
7	540885859	OTHER	VA	FOCUS
8	540885859	OTHER	VA	MULTIPLAN
9	540885859	OTHER	VA	CENVANET
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	536767	OTHER	VA	AETNA/US HMO
12	540885859	OTHER	VA	PHCS
13	540885859	OTHER	VA	CIGNA
14	540885859	OTHER	VA	COMPMANAGEMENT
16	48192	OTHER	VA	OPTIMA HEALTH
17	540885859	OTHER	VA	CORVEL
18	540885859	OTHER	VA	FIRST HEALTH/CCN

General Provider Information

NPI Number	:	1548214372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDWIN DEBLOIS M.D.

Provider Business Mailing Address
First Line	:	1115 BOULDERS PKWY
Second Line	:	SUITE 200
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23225-4067
Country	:	US
Telephone Number	:	804-560-5595
Fax Number	:	804-560-9029

Provider Business Practice Location Address
First Line	:	1115 BOULDERS PKWY
Second Line	:	SUITE 100
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23225-4067
Country	:	US
Telephone Number	:	804-320-1339
Fax Number	:	804-330-5829

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	01/28/2013

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