Healthcare Provider Details

I. General information

NPI: 1356961015
Provider Name (Legal Business Name): ALEXANDER BLANK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W WASHINGTON ST STE 1801
CHICAGO IL
60602-3430
US

IV. Provider business mailing address

111 W WASHINGTON ST STE 1801
CHICAGO IL
60602-3430
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8106
  • Fax: 312-694-1340
Mailing address:
  • Phone: 312-695-8106
  • Fax: 312-694-1340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: