Provider Demographics
NPI:1760437545
Name:BLAISDELL, CAROL (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BLAISDELL
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:PO BOX 62063
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2063
Mailing Address - Country:US
Mailing Address - Phone:410-706-5181
Mailing Address - Fax:410-706-5103
Practice Address - Street 1:160 E ERIE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1011
Practice Address - Country:US
Practice Address - Phone:215-427-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD42102080P0214X
PAMD4829092080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD302691400Medicaid
F89840Medicare UPIN