Provider Demographics
NPI:1194942417
Name:MACDONALD, BLAINE M (DC)
Entity type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:M
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 12TH ST E
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-2203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 12TH ST E
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-2203
Practice Address - Country:US
Practice Address - Phone:320-864-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN189K2PEOtherGROUP BCBS PROVIDER NUMBE
MN184R7MAOtherBCBS PIN NUMBER
MN184R7MAOtherBCBS PIN NUMBER