Healthcare Provider Details

I. General information

NPI: 1396736070
Provider Name (Legal Business Name): HAL H BLANK CSA OPAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7073 STONECREEK DR
PLAINFIELD IN
46168-7923
US

IV. Provider business mailing address

7073 STONECREEK DR
PLAINFIELD IN
46168-7923
US

V. Phone/Fax

Practice location:
  • Phone: 317-838-8999
  • Fax: 317-838-8999
Mailing address:
  • Phone: 317-838-8999
  • Fax: 317-838-8999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0000097
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA081
License Number StateKY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: