Basic Information
| Provider Information | |||||||||
| NPI: | 1487674156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | MICAHEL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 9548392569 | ||||||||
| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE ROAD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511754 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 00638 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367H00000X | 000638 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000412156 | 05 | GA | MEDICAID | 455538491E | 05 | GA | MEDICAID |