Healthcare Provider Details

I. General information

NPI: 1578568572
Provider Name (Legal Business Name): SCOTT ALAN BLICKENSDERFER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 UNIVERSITY COMMONS STE 350
SOUTH BEND IN
46635-1571
US

IV. Provider business mailing address

6301 UNIVERSITY COMMONS STE 230
SOUTH BEND IN
46635-1571
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-4100
  • Fax: 574-282-1739
Mailing address:
  • Phone: 574-251-2100
  • Fax: 574-251-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number02001398A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: