Provider Demographics
NPI:1962684530
Name:MARK A BLAIR MD PC
Entity Type:Organization
Organization Name:MARK A BLAIR MD PC
Other - Org Name:PARADISE VALLEY DERMATOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-971-0950
Mailing Address - Street 1:12251 N 32ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-7189
Mailing Address - Country:US
Mailing Address - Phone:602-971-0950
Mailing Address - Fax:
Practice Address - Street 1:12251 N 32ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7189
Practice Address - Country:US
Practice Address - Phone:602-971-0950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ79349Medicare PIN