Provider Demographics
NPI:1497883300
Name:BENJAMIN BLAIR, MD PA
Entity Type:Organization
Organization Name:BENJAMIN BLAIR, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-233-2100
Mailing Address - Street 1:2240 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2600
Mailing Address - Country:US
Mailing Address - Phone:208-233-2100
Mailing Address - Fax:208-233-3146
Practice Address - Street 1:2240 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2600
Practice Address - Country:US
Practice Address - Phone:208-233-2100
Practice Address - Fax:208-233-3146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7032174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0000100002014OtherBLUE SHIELD OF IDAHO
ID8K305OtherBLUE CROSS GROUP ID #
ID002756000Medicaid
185513400OtherUS DEPT OF LABOR
DA7257OtherRAILROAD MEDICARE GRP ID
DA7257OtherRAILROAD MEDICARE GRP ID
ID002756000Medicaid
ID8K305OtherBLUE CROSS GROUP ID #