Provider Demographics
NPI:1790500874
Name:ANDERSON, BLAIR J
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1723
Mailing Address - Country:US
Mailing Address - Phone:313-915-8540
Mailing Address - Fax:
Practice Address - Street 1:861 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-1723
Practice Address - Country:US
Practice Address - Phone:313-915-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker