Healthcare Provider Details

I. General information

NPI: 1134156979
Provider Name (Legal Business Name): BLAIR MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 9TH AVE
ALTOONA PA
16602-2454
US

IV. Provider business mailing address

1414 9TH AVE STATION MEDICAL CENTER
ALTOONA PA
16602-2415
US

V. Phone/Fax

Practice location:
  • Phone: 814-949-7621
  • Fax: 814-949-7616
Mailing address:
  • Phone: 814-949-7621
  • Fax: 814-949-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC002353L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1007393100001
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPODIATRY MED. ASST. #
# 2
Identifier0719120001
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerDMERC PROVIDER NUMBER
# 3
Identifier1015429
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPODIATRY GHP #
# 4
Identifier117185
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK

VIII. Authorized Official

Name: JENNIFER BRYAN
Title or Position: PROJECTS MGR.
Credential:
Phone: 81494976211