MEDICARE: JERRY R BLAIR M.D., PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207WX0107X	Retina Specialist (Ophthalmology) Physician	108058	MO
2	207W00000X	Ophthalmology Physician	108058	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5388	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1790769701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY R BLAIR M.D., PH.D.

Provider Business Mailing Address
First Line	:	3600 AMRON CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-1918
Country	:	US
Telephone Number	:	573-874-1616
Fax Number	:	573-875-0300

Provider Business Practice Location Address
First Line	:	3600 AMRON CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-1918
Country	:	US
Telephone Number	:	573-874-1616
Fax Number	:	573-875-0300

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	04/10/2017

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