Provider Demographics
NPI:1952319063
Name:BLAIR NEUROLOGIC ASSOCIATES
Entity Type:Organization
Organization Name:BLAIR NEUROLOGIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PRIMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-201-2309
Mailing Address - Street 1:914 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6247
Mailing Address - Country:US
Mailing Address - Phone:814-201-2309
Mailing Address - Fax:814-301-2389
Practice Address - Street 1:914 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6247
Practice Address - Country:US
Practice Address - Phone:814-201-2309
Practice Address - Fax:814-301-2389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038175E2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019607820001Medicaid
PA0019607820001Medicaid