Healthcare Provider Details

I. General information

NPI: 1639116254
Provider Name (Legal Business Name): MARK M BLAIR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 PEPPERELL PKWY
OPELIKA AL
36801-5452
US

IV. Provider business mailing address

PO BOX 627
AUBURN AL
36831-0627
US

V. Phone/Fax

Practice location:
  • Phone: 334-528-2499
  • Fax:
Mailing address:
  • Phone: 800-232-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209001203
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-094483
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: