Healthcare Provider Details

I. General information

NPI: 1538553797
Provider Name (Legal Business Name): BLAIR JOHNSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 E IRELAND RD STE 100
SOUTH BEND IN
46614-2845
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-5790
  • Fax: 574-647-5792
Mailing address:
  • Phone: 574-647-1610
  • Fax: 574-237-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number36000299A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: