=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740646181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KSENIA NIKOLAYEVNA BLINNIKOVA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2016
-----------------------------------------------------
Last Update Date | 08/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 STANIFORD ST FL 9
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02114-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-724-6610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 STANIFORD ST FL 9
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02114-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-724-6610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 37486
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 1013709
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 1013709
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------