Healthcare Provider Details

I. General information

NPI: 1538385117
Provider Name (Legal Business Name): BLAIR FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E MAIN ST
WALLACE NC
28466-2726
US

IV. Provider business mailing address

404 E MAIN ST
WALLACE NC
28466-2726
US

V. Phone/Fax

Practice location:
  • Phone: 910-285-3380
  • Fax:
Mailing address:
  • Phone: 910-285-3380
  • Fax:

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: DR. MOTT PARKS BLAIR IV
Title or Position: OWNER
Credential: MD
Phone: 910-285-2134