Provider Demographics
NPI:1427436567
Name:CHADWICK, BLAINE
Entity type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:
Last Name:CHADWICK
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 1:710 BAIR ISLAND RD APT 401
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-5550
Mailing Address - Country:US
Mailing Address - Phone:480-452-6901
Mailing Address - Fax:
Practice Address - Street 1:710 BAIR ISLAND RD APT 401
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-5550
Practice Address - Country:US
Practice Address - Phone:480-452-6901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD02509144242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist