Provider Demographics
NPI:1518910900
Name:BLAIR, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:161-668-5180
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:150 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4306
Practice Address - Country:US
Practice Address - Phone:616-685-8450
Practice Address - Fax:616-458-3526
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4194566Medicaid
MI2994936Medicaid
MI4878515Medicaid
MI2994936Medicaid
MIP32930119Medicare ID - Type Unspecified
MI4194566Medicaid
MI4878515Medicaid