Provider Demographics
NPI:1992719777
Name:BLANCHARD, KEVIN P (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:BLANCHARD
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5680
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5680
Practice Address - Fax:601-268-5778
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16509207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640507572XJOtherAMERICAN ADMIN GROUP
MS00124393Medicaid
LA1035211Medicaid
MS00124393Medicaid
LA1035211Medicaid
MS640507572XJOtherAMERICAN ADMIN GROUP