Healthcare Provider Details

I. General information

NPI: 1801076146
Provider Name (Legal Business Name): MICHAEL ANTHONY BLAIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2007
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 US HIGHWAY 45 N
ELDORADO IL
62930-3770
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-273-2951
  • Fax: 618-273-2726
Mailing address:
  • Phone: 618-724-2401
  • Fax: 618-724-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036122763
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number036122763
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: