Provider Demographics
NPI:1427243872
Name:JENNIFER M. BLAIR, M.D., L.L.C.
Entity type:Organization
Organization Name:JENNIFER M. BLAIR, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-282-5616
Mailing Address - Street 1:192 MANSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3539
Mailing Address - Country:US
Mailing Address - Phone:312-282-5616
Mailing Address - Fax:312-282-5616
Practice Address - Street 1:2000 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7222
Practice Address - Country:US
Practice Address - Phone:847-697-8868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117811207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117811Medicaid
ILK44547Medicare PIN