Healthcare Provider Details

I. General information

NPI: 1013479856
Provider Name (Legal Business Name): TRAVIS GLENN BLANTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 HOSPITAL DR
LOGAN WV
25601-3452
US

IV. Provider business mailing address

2181 TOWNSHIP ROAD 188
CARDINGTON OH
43315-9353
US

V. Phone/Fax

Practice location:
  • Phone: 304-831-1101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number306742
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.148574
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number35.148574
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number35401
License Number StateWV
# 5
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35401
License Number StateWV
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number306742
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: