Healthcare Provider Details

I. General information

NPI: 1255391413
Provider Name (Legal Business Name): HERMAN MACK BLANTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MARY ST
EVANSVILLE IN
47710-1674
US

IV. Provider business mailing address

PO BOX 3407
EVANSVILLE IN
47733-3407
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-7338
  • Fax: 812-450-2193
Mailing address:
  • Phone: 812-450-7338
  • Fax: 812-450-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01077468A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: