MEDICARE: DR. KEVIN A. BLAU D.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	111N00000X	Chiropractor	2990	WI

Other Identifiers

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

General Provider Information

NPI Number	:	1932194172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN A. BLAU D.C.

Provider Business Mailing Address
First Line	:	641 LATTON LN
Second Line	:	SUITE A
City	:	PORTAGE
State	:	WI
Zip	:	53901-1078
Country	:	US
Telephone Number	:	608-742-1300
Fax Number	:	608-745-0147

Provider Business Practice Location Address
First Line	:	641 LATTON LN
Second Line	:	SUITE A
City	:	PORTAGE
State	:	WI
Zip	:	53901-1078
Country	:	US
Telephone Number	:	608-742-1300
Fax Number	:	608-745-0147

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

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	07/09/2007

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