Basic Information
| Provider Information | |||||||||
| NPI: | 1770745309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLATZ | ||||||||
| FirstName: | BRICE | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | MD, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9925 SW NIMBUS AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970087591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032176305 | ||||||||
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| Practice Location | |||||||||
| Address1: | 221 MICHIGAN ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163911405 | ||||||||
| FaxNumber: | 6163918611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | LL2132 | NV | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 4301092779 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | LL2132 | 01 | NV | REG. MEDICAL LIC. | OTHER |