Provider Demographics
NPI:1861675746
Name:KEITH BLAIR
Entity Type:Organization
Organization Name:KEITH BLAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-562-7676
Mailing Address - Street 1:725 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-1463
Mailing Address - Country:US
Mailing Address - Phone:419-562-7676
Mailing Address - Fax:419-562-8469
Practice Address - Street 1:725 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1463
Practice Address - Country:US
Practice Address - Phone:419-562-7676
Practice Address - Fax:419-562-8469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037333B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0246335Medicaid
OHA74864Medicare UPIN
OH9341761Medicare PIN