Basic Information
| Provider Information | |||||||||
| NPI: | 1669828166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | CASI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BLANTON | ||||||||
| OtherFirstName: | CASI | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 CHARLTON CT | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461227825 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 BARNHILL DR BLDG 116 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172740076 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2016 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 11022342A | IN | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 86268 | SC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1669828166 | 05 | NC | MEDICAID |