Healthcare Provider Details

I. General information

NPI: 1326082397
Provider Name (Legal Business Name): BLANE A MIRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 SERGEANT PRENTISS DR SUITE 300
NATCHEZ MS
39120-4725
US

IV. Provider business mailing address

209 GLENWOOD DR
NATCHEZ MS
39120-4707
US

V. Phone/Fax

Practice location:
  • Phone: 601-446-7343
  • Fax: 601-445-0833
Mailing address:
  • Phone: 601-446-8599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15913
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: