Healthcare Provider Details

I. General information

NPI: 1609040310
Provider Name (Legal Business Name): CHRISTINE MARIE BLAINE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E MAIN ST SUITE #6
HUNTINGTON NY
11743-2845
US

IV. Provider business mailing address

110 E MAIN ST SUITE #6
HUNTINGTON NY
11743-2845
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-3600
  • Fax: 631-424-2963
Mailing address:
  • Phone: 631-424-3600
  • Fax: 631-424-2963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMT186094
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number265036-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: