Provider Demographics
NPI:1306020938
Name:B .GLENN BLAIR DPM P.C.
Entity Type:Organization
Organization Name:B .GLENN BLAIR DPM P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-929-5559
Mailing Address - Street 1:375 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-3844
Mailing Address - Country:US
Mailing Address - Phone:203-929-5559
Mailing Address - Fax:203-929-5277
Practice Address - Street 1:375 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-3844
Practice Address - Country:US
Practice Address - Phone:203-929-5559
Practice Address - Fax:203-929-5277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000419213EP1101X, 213ER0200X, 213ES0131X
CTCT000419332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004176815Medicaid
CTC02031Medicare PIN
CT1229830001Medicare NSC