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General NPI Number Information
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NPI Number | 1427651587
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Entity Type | Organization
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Legal Business Name | BLAIR MEDICAL LLC
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Dates
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Enumeration Date | 11/19/2020
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 13745 MARY LN
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City | AVISTON
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State | IL
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Zip | 62216-4732
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Country | US
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Telephone | 618-567-9821
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Fax | 618-939-9836
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Provider Business Mailing Address
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Address Line | PO BOX 306
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City | COLUMBIA
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State | IL
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Zip | 62236-0306
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Country | US
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Telephone | 618-567-9821
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Fax | 618-939-9836
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Authorized Official
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Title or Position | OWNER, AUTHORIZED
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Name | BLAIR E BONE
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Credential | NP
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Telephone | 618-567-9821
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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