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General NPI Number Information
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NPI Number | 1770557472
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Entity Type | Individual
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Provider Name | DALE W BLAISE MD
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Gender | Male
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Dates
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Enumeration Date | 02/17/2006
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Last Update Date | 08/24/2022
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Provider Practice Location Address
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Address Line | 19 E SHAWNEE DR STE 2
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City | MURPHYSBORO
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State | IL
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Zip | 62966-7072
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Country | US
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Telephone | 618-684-2172
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Fax | 618-687-4480
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Provider Business Mailing Address
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Address Line | PO BOX 3988
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City | CARBONDALE
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State | IL
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Zip | 62902-3988
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Country | US
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Telephone | 618-457-5200
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036065426
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License Number State | IL
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