Provider Demographics
NPI:1861458424
Name:BLAICH, PHILLIP WAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:WAYNE
Last Name:BLAICH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TWINING ST BLDG 760
Mailing Address - Street 2:
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112-6027
Mailing Address - Country:US
Mailing Address - Phone:334-953-8607
Mailing Address - Fax:850-747-2222
Practice Address - Street 1:300 TWINING ST BLDG 760
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112-6027
Practice Address - Country:US
Practice Address - Phone:334-953-8607
Practice Address - Fax:850-747-2222
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003348363AM0700X
FLPA9103668363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020471300Medicaid
820900Medicare PIN
S76910Medicare UPIN