MEDICARE: BRUCE HENRY 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	208800000X	Urology Physician	MD09769	OR

General Provider Information

NPI Number	:	1992809966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE HENRY BLANK M.D.

Provider Business Mailing Address
First Line	:	164 NW MACLEAY BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-3323
Country	:	US
Telephone Number	:	503-228-1253
Fax Number	:	503-228-1797

Provider Business Practice Location Address
First Line	:	164 NW MACLEAY BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-3323
Country	:	US
Telephone Number	:	503-228-1253
Fax Number	:	503-228-1797

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

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	07/08/2007

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