MEDICARE: DR. RONALD RAY BLANCK D.O.

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	207R00000X	Internal Medicine Physician	C2-0003963	DE

General Provider Information

NPI Number	:	1871772301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD RAY BLANCK D.O.

Provider Business Mailing Address
First Line	:	1613 BAY ST
Second Line	:
City	:	FENWICK ISLAND
State	:	DE
Zip	:	19944-4506
Country	:	US
Telephone Number	:	302-541-4137
Fax Number	:	302-541-4137

Provider Business Practice Location Address
First Line	:	1613 BAY ST
Second Line	:
City	:	FENWICK ISLAND
State	:	DE
Zip	:	19944-4506
Country	:	US
Telephone Number	:	302-541-4137
Fax Number	:	302-541-4137

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

Provider Enumeration Date	:	11/01/2007
Last Update Date	:	11/01/2007

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