Provider Demographics
NPI:1487713723
Name:VITALE, BLAISE PAUL (MD)
Entity type:Individual
Prefix:
First Name:BLAISE
Middle Name:PAUL
Last Name:VITALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 W SAINT GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7827
Mailing Address - Country:US
Mailing Address - Phone:715-463-5353
Mailing Address - Fax:715-463-2423
Practice Address - Street 1:257 W SAINT GEORGE AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7827
Practice Address - Country:US
Practice Address - Phone:715-463-5317
Practice Address - Fax:715-463-2753
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31761500Medicaid
MN660085900Medicaid
WI000509035Medicare PIN
WIE09867Medicare UPIN