Healthcare Provider Details

I. General information

NPI: 1356379069
Provider Name (Legal Business Name): KIMBERLY A BLAIR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 HIGH STREET
WADSWORTH OH
44281
US

IV. Provider business mailing address

1225 HIGH STREET
WADSWORTH OH
44281
US

V. Phone/Fax

Practice location:
  • Phone: 330-335-7337
  • Fax:
Mailing address:
  • Phone: 330-335-7337
  • Fax: 330-334-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35076807
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-07-6807
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: