Healthcare Provider Details

I. General information

NPI: 1174935217
Provider Name (Legal Business Name): EDDIE BLAY JR. M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 PENNSYLVANIA AVE STE 690
FORT WORTH TX
76104-2133
US

IV. Provider business mailing address

1325 PENNSYLVANIA AVE STE 690
FORT WORTH TX
76104-2133
US

V. Phone/Fax

Practice location:
  • Phone: 817-761-7740
  • Fax: 817-761-7742
Mailing address:
  • Phone: 314-251-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036170087
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number43923-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number67923
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberV8108
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036170087
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number43923-20
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number2024010643
License Number StateMO
# 8
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberV8108
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: