MEDICARE: MR. BLAINE HAVENS SA-C, TS-C

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	246ZC0007X	Surgical Assistant	26-125	MD

General Provider Information

NPI Number	:	1750231403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BLAINE HAVENS SA-C, TS-C

Provider Business Mailing Address
First Line	:	14320 W SIDE BLVD APT 303
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-6260
Country	:	US
Telephone Number	:	440-941-7716
Fax Number	:

Provider Business Practice Location Address
First Line	:	14320 W SIDE BLVD APT 303
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-6260
Country	:	US
Telephone Number	:	440-941-7716
Fax Number	:

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

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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