Healthcare Provider Details

I. General information

NPI: 1134167950
Provider Name (Legal Business Name): HARLEY MYRON BLANK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 E BROAD ST
COLUMBUS OH
43205
US

IV. Provider business mailing address

5969 E BROAD ST SUITE 301
COLUMBUS OH
43213-1546
US

V. Phone/Fax

Practice location:
  • Phone: 146-251-1800
  • Fax: 614-251-1818
Mailing address:
  • Phone: 614-864-0670
  • Fax: 614-864-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number35027415
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: