Healthcare Provider Details

I. General information

NPI: 1255709218
Provider Name (Legal Business Name): NIMROD BLANK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22720 MICHIGAN AVE STE 200
DEARBORN MI
48124-2021
US

IV. Provider business mailing address

22720 MICHIGAN AVE STE 200
DEARBORN MI
48124-2021
US

V. Phone/Fax

Practice location:
  • Phone: 313-791-3000
  • Fax: 313-791-2800
Mailing address:
  • Phone: 313-791-3000
  • Fax: 313-791-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number4301108677
License Number StateFM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301108677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: