Provider Demographics
NPI:1447350236
Name:BLASINGAME, KEITH S (PT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:S
Last Name:BLASINGAME
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10223 BROADWAY ST STE B
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7881
Mailing Address - Country:US
Mailing Address - Phone:713-436-3900
Mailing Address - Fax:173-436-3904
Practice Address - Street 1:10223 W BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584
Practice Address - Country:US
Practice Address - Phone:713-436-3900
Practice Address - Fax:713-436-3904
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1092377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153447101Medicaid
TXP08696Medicare UPIN