Healthcare Provider Details

I. General information

NPI: 1043366628
Provider Name (Legal Business Name): ELIZABETH ANN BLANK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 MAIN ST STE 200
PRINCE FREDERICK MD
20678-3190
US

IV. Provider business mailing address

497 MAIN ST STE 200
PRINCE FREDERICK MD
20678-3190
US

V. Phone/Fax

Practice location:
  • Phone: 410-414-9840
  • Fax: 410-414-9841
Mailing address:
  • Phone: 410-414-9840
  • Fax: 410-414-9841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD0082740
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: