Provider Demographics
NPI:1346701109
Name:BLOTEVOGEL, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BLOTEVOGEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 KENTUCKY AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3825
Mailing Address - Country:US
Mailing Address - Phone:270-538-9555
Mailing Address - Fax:270-538-9554
Practice Address - Street 1:2601 KENTUCKY AVE STE 201
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3825
Practice Address - Country:US
Practice Address - Phone:270-538-9555
Practice Address - Fax:270-538-9554
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59247208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery