Provider Demographics
NPI:1891868980
Name:BLAIR, SCOTT D (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
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 1:3434 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3291
Mailing Address - Country:US
Mailing Address - Phone:712-325-0022
Mailing Address - Fax:712-325-8102
Practice Address - Street 1:3434 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3291
Practice Address - Country:US
Practice Address - Phone:712-325-0022
Practice Address - Fax:712-325-8102
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
21071OtherCOVENTRY
IA1034330Medicaid
0100253OtherUNITED HEALTH CARE
IA24684OtherWELLMARK
IA24684OtherWELLMARK
0100253OtherUNITED HEALTH CARE
IAI19105Medicare ID - Type UnspecifiedNEW NUMBER EFF JAN 1 2006