Provider Demographics
NPI:1962926311
Name:ANDERSON, BLAIRE LORI (MD)
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:LORI
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2932
Mailing Address - Street 2:
Mailing Address - City:ALBERTA
Mailing Address - State:CANADA
Mailing Address - Zip Code:T1P1L5
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4921 PARKVIEW PLACE STE 8C
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-747-1369
Practice Address - Fax:314-367-1943
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2018-03-06
Deactivation Date:2018-03-01
Deactivation Code:
Reactivation Date:2018-03-06
Provider Licenses
StateLicense IDTaxonomies
MO2017021157208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery