Provider Demographics
NPI:1740207398
Name:BLAIR, ELIZABETH IVEY (MD PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:IVEY
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-0278
Mailing Address - Country:US
Mailing Address - Phone:910-275-0060
Mailing Address - Fax:910-275-0162
Practice Address - Street 1:417 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-8801
Practice Address - Country:US
Practice Address - Phone:910-275-0060
Practice Address - Fax:910-275-0162
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39546208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F23481Medicare UPIN