Healthcare Provider Details

I. General information

NPI: 1538389457
Provider Name (Legal Business Name): HEIDI BLAIR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1167 COUNTY ROAD 437 STE B
CULLMAN AL
35055-0203
US

IV. Provider business mailing address

1167 COUNTY ROAD 437 STE B
CULLMAN AL
35055-0203
US

V. Phone/Fax

Practice location:
  • Phone: 256-735-4632
  • Fax: 256-735-4639
Mailing address:
  • Phone: 256-735-4632
  • Fax: 256-735-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19923
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier138096
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: