Healthcare Provider Details

I. General information

NPI: 1851478192
Provider Name (Legal Business Name): BENJAMIN BLAIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

IV. Provider business mailing address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2100
  • Fax: 208-233-3146
Mailing address:
  • Phone: 208-233-2100
  • Fax: 208-233-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM-7032
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberM-7032
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: