Provider Demographics
NPI:1942254677
Name:BLAIR, MADONNA MORGAN (AUD)
Entity Type:Individual
Prefix:DR
First Name:MADONNA
Middle Name:MORGAN
Last Name:BLAIR
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MADONN
Other - Middle Name:NICOLE
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:2295 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7801
Mailing Address - Country:US
Mailing Address - Phone:843-766-7103
Mailing Address - Fax:
Practice Address - Street 1:2801 DEVINE ST STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2511
Practice Address - Country:US
Practice Address - Phone:843-766-7103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA-0377237600000X
SC3890231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE5192OtherUNSPECIFIED
SC8416Medicare PIN