MEDICARE: ELIZABETH IVEY BLAIR MD PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	39546	NC

General Provider Information

NPI Number	:	1740207398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH IVEY BLAIR MD PHD

Provider Business Mailing Address
First Line	:	PO BOX 278
Second Line	:
City	:	KENANSVILLE
State	:	NC
Zip	:	28349-0278
Country	:	US
Telephone Number	:	910-275-0060
Fax Number	:	910-275-0162

Provider Business Practice Location Address
First Line	:	417 N MAIN ST
Second Line	:
City	:	KENANSVILLE
State	:	NC
Zip	:	28349-8801
Country	:	US
Telephone Number	:	910-275-0060
Fax Number	:	910-275-0162

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	01/06/2022

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