Provider Demographics
NPI:1922640739
Name:BLAIR, JEREMIAH GEORGE (PA)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:GEORGE
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:100 STONEFOREST DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4881
Mailing Address - Country:US
Mailing Address - Phone:770-423-0595
Mailing Address - Fax:678-388-1627
Practice Address - Street 1:61 WHITCHER ST SUITE 2100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-423-0595
Practice Address - Fax:678-391-5055
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2022-11-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
363AS0400X
GA9359208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical