Healthcare Provider Details

I. General information

NPI: 1588739593
Provider Name (Legal Business Name): MARIE BLAIR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NORTHERN BOULEVARD SUITE 109
GREAT NECK NY
11021
US

IV. Provider business mailing address

600 NORTHERN BOULEVARD SUITE 109
GREAT NECK NY
11021
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-8775
  • Fax: 516-466-7616
Mailing address:
  • Phone: 516-674-8775
  • Fax: 516-466-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number128815
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: