Healthcare Provider Details

I. General information

NPI: 1770565699
Provider Name (Legal Business Name): TARA L. F. BLASINGAME D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 W DUBLIN DR SUITE A
MADISON AL
35758-1787
US

IV. Provider business mailing address

PO BOX 6487
HUNTSVILLE AL
35813-0487
US

V. Phone/Fax

Practice location:
  • Phone: 256-772-8566
  • Fax: 256-774-8211
Mailing address:
  • Phone: 256-772-8566
  • Fax: 256-774-8211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberAL164
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number714
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: