Healthcare Provider Details

I. General information

NPI: 1528035821
Provider Name (Legal Business Name): MEDICAL ARTS CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 E SHAWNEE DR
MURPHYSBORO IL
62966-7049
US

IV. Provider business mailing address

19 E SHAWNEE DR
MURPHYSBORO IL
62966-7049
US

V. Phone/Fax

Practice location:
  • Phone: 618-684-2172
  • Fax: 618-687-4480
Mailing address:
  • Phone: 618-684-2172
  • Fax: 618-687-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DALE W BLAISE
Title or Position: PRESIDENT
Credential: MD
Phone: 618-684-2172