Healthcare Provider Details

I. General information

NPI: 1508869561
Provider Name (Legal Business Name): MARK BLAIR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WILLIAM NORTHERN BLVD
TULLAHOMA TN
37388-4754
US

IV. Provider business mailing address

PO BOX 910
TULLAHOMA TN
37388-0910
US

V. Phone/Fax

Practice location:
  • Phone: 931-461-1150
  • Fax: 888-498-3372
Mailing address:
  • Phone: 931-461-1150
  • Fax: 888-498-3372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD34454
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: