Provider Demographics
NPI:1851478192
Name:BLAIR, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
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 1:2240 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7032207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID72405OtherBLUE CROSS OF ID
ID185513400OtherUS DEPT OF LABOR
ID200034945OtherRAILROAD MEDICARE
ID1497883300Medicaid
ID200034945OtherRAILROAD MEDICARE
IDG18408Medicare UPIN
ID1102172Medicare PIN