Healthcare Provider Details

I. General information

NPI: 1659342913
Provider Name (Legal Business Name): THOMAS J BLANKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE STE 420
SAINT LOUIS MO
63108-1402
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8109
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9100
  • Fax: 314-362-9107
Mailing address:
  • Phone: 314-362-9100
  • Fax: 314-362-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number33592
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number33592
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: