Provider Demographics
NPI:1215997184
Name:BLAIR, MICHAEL P (MSPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 BURKE CENTRE PKWY
Mailing Address - Street 2:#300
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3750
Mailing Address - Country:US
Mailing Address - Phone:703-978-3300
Mailing Address - Fax:
Practice Address - Street 1:6035 BURKE CENTRE PKWY
Practice Address - Street 2:#300
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3750
Practice Address - Country:US
Practice Address - Phone:703-978-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1147225100000X
VA2305207779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313920OtherBLUE CROSS BLUE SHIELD
WYP00250413OtherRAILROAD MEDICARE
WY121814000Medicaid
WY121814000Medicaid