Healthcare Provider Details

I. General information

NPI: 1043202047
Provider Name (Legal Business Name): CAROL A BLANK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HUNTERS TRL
GETTYSBURG PA
17325-7281
US

IV. Provider business mailing address

11 HUNTERS TRL
GETTYSBURG PA
17325-7281
US

V. Phone/Fax

Practice location:
  • Phone: 717-334-7681
  • Fax: 717-334-0730
Mailing address:
  • Phone: 717-334-7681
  • Fax: 717-334-0730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD069190L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0017562320001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: