=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841906203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENNETT MARK BLASKEY PHYSICAL THERAPIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2023
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 SAVANNAH RD STE A1
-----------------------------------------------------
City | LEWES
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19958-1550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-644-2530
-----------------------------------------------------
Fax | 302-644-2556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10613 N UNION CHURCH RD
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19960-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-424-3266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | J1-0000153
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------