Provider Demographics
NPI:1093821605
Name:BLAIR, EDWARD B JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:B
Last Name:BLAIR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2 SAINT ANTHONYS WAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-462-2222
Mailing Address - Fax:618-462-1150
Practice Address - Street 1:2 SAINT ANTHONYS WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-462-2222
Practice Address - Fax:618-463-5004
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-01-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036060205207R00000X
IL036.060205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060205Medicaid
IL110191309OtherRAILROAD MEDICARE
IL036060205Medicaid