Healthcare Provider Details

I. General information

NPI: 1306020938
Provider Name (Legal Business Name): B .GLENN BLAIR DPM P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 BRIDGEPORT AVE
SHELTON CT
06484-3844
US

IV. Provider business mailing address

375 BRIDGEPORT AVE
SHELTON CT
06484-3844
US

V. Phone/Fax

Practice location:
  • Phone: 203-929-5559
  • Fax: 203-929-5277
Mailing address:
  • Phone: 203-929-5559
  • Fax: 203-929-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number000419
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number000419
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberCT000419
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number000419
License Number StateCT

VIII. Authorized Official

Name: MRS. JULIE M RUSSELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 203-929-5559