Provider Demographics
NPI:1508869561
Name:BLAIR, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-0910
Mailing Address - Country:US
Mailing Address - Phone:931-461-1150
Mailing Address - Fax:888-498-3372
Practice Address - Street 1:100 WILLIAM NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-4754
Practice Address - Country:US
Practice Address - Phone:931-461-1150
Practice Address - Fax:888-498-3372
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD34454208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN020053847OtherIND RRMCR #
TN7201687OtherCIGNA HEALTHCARE
TN3856436Medicaid
TN4043202OtherBCBS OF TN
TN4043202OtherBCBS OF TN
TN7201687OtherCIGNA HEALTHCARE