Provider Demographics
NPI:1427651587
Name:BLAIR MEDICAL LLC
Entity type:Organization
Organization Name:BLAIR MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUTHORIZED
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:E
Authorized Official - Last Name:BONE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:618-567-9821
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-0306
Mailing Address - Country:US
Mailing Address - Phone:618-567-9821
Mailing Address - Fax:618-939-9836
Practice Address - Street 1:13745 MARY LN
Practice Address - Street 2:
Practice Address - City:AVISTON
Practice Address - State:IL
Practice Address - Zip Code:62216-4732
Practice Address - Country:US
Practice Address - Phone:618-567-9821
Practice Address - Fax:618-939-9836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-19
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty