1104489111 NPI number — MICHELLE RAE BLAIR NP-C

Table of content: MICHELLE RAE BLAIR NP-C (NPI 1104489111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104489111 NPI number — MICHELLE RAE BLAIR NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAIR
Provider First Name:
MICHELLE
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104489111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/02/2019
NPI Reactivation Date:
06/03/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 639917
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-9917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8161 WARREN H ABERNATHY HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29301-2451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-586-1152
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  0024177529 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 24897 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP7525 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: SCK1055019 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SCK1056084 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SCK1056067 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SCK105J577 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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