MEDICARE: NANCY MARIE BLANK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	MD0000015363	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30092801	OTHER	TN	MEDICARE ID - PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356346720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY MARIE BLANK M.D.

Provider Business Mailing Address
First Line	:	2560 BUSINESS PARK DR NE
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-6503
Country	:	US
Telephone Number	:	423-472-5401
Fax Number	:	423-479-3060

Provider Business Practice Location Address
First Line	:	2560 BUSINESS PARK DR NE
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-6503
Country	:	US
Telephone Number	:	423-472-5401
Fax Number	:	423-479-3060

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	11/30/2010

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