Provider Demographics
NPI:1477587822
Name:BLAISE, MARLENE LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:LOUISE
Last Name:BLAISE
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 1:3400-C OLD MILTON PKWY
Mailing Address - Street 2:SUITE 325
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4433
Mailing Address - Country:US
Mailing Address - Phone:678-762-0910
Mailing Address - Fax:678-762-0920
Practice Address - Street 1:3400-C OLD MILTON PKWY
Practice Address - Street 2:SUITE 325
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4433
Practice Address - Country:US
Practice Address - Phone:678-762-0910
Practice Address - Fax:678-762-0920
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48028207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000850132BMedicaid
GA000850132BMedicaid
G52731Medicare UPIN