Provider Demographics
NPI:1972590172
Name:MARK BLAIR MD PC
Entity Type:Organization
Organization Name:MARK BLAIR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-461-1150
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-0910
Mailing Address - Country:US
Mailing Address - Phone:931-461-1150
Mailing Address - Fax:888-498-3372
Practice Address - Street 1:100 WILLIAM NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-4754
Practice Address - Country:US
Practice Address - Phone:931-461-1150
Practice Address - Fax:888-498-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4043202OtherBCBS
TN3370034Medicaid
TN7201687OtherCIGNA
TN7201687OtherCIGNA
TNDA3882Medicare ID - Type UnspecifiedGRP RRMCR
TN3370034Medicare ID - Type UnspecifiedGRP MCARE