=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023014420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAIR BRENGLE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2005
-----------------------------------------------------
Last Update Date | 01/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8803 N MERIDIAN STREET SUITE 350
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-252-1219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8803 N MERIDIAN STREET SUITE 350
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-252-1219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01043339
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------