Provider Demographics
NPI:1134148182
Name:BLAIR, KENNETH MORRIS (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MORRIS
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 ERIE CT
Mailing Address - Street 2:SUITE 6160
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2566
Mailing Address - Country:US
Mailing Address - Phone:708-763-1490
Mailing Address - Fax:708-763-7232
Practice Address - Street 1:1 ERIE CT
Practice Address - Street 2:SUITE 6160
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2566
Practice Address - Country:US
Practice Address - Phone:708-763-1490
Practice Address - Fax:708-763-7232
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-08-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-053547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD14035Medicare UPIN