Healthcare Provider Details

I. General information

NPI: 1366937138
Provider Name (Legal Business Name): BLAINE T MANNING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 DOUGHERTY FERRY RD STE 100
SAINT LOUIS MO
63122-3356
US

IV. Provider business mailing address

1120 15TH ST # OR6000
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-1359
  • Fax: 314-909-1370
Mailing address:
  • Phone: 706-721-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number95437
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2018020296
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: