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General NPI Number Information
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NPI Number | 1790117356
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Entity Type | Individual
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Provider Name | BENJAMIN MICHAEL BLICK CRNA
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Gender | Male
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Dates
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Enumeration Date | 08/06/2013
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 327 MEDICAL PARK DR
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City | BRIDGEPORT
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State | WV
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Zip | 26330-9006
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Country | US
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Telephone | 681-342-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 145 KINGSTON DR
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City | BRIDGEPORT
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State | WV
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Zip | 26330-1588
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Country | US
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Telephone | 434-996-6303
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 90749
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 77620
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License Number State | WV
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