Basic Information
| Provider Information | |||||||||
| NPI: | 1396833588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAISE | ||||||||
| FirstName: | MARIE-NIRVA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 653 LAWRENCE ST | ||||||||
| Address2: | |||||||||
| City: | ELMONT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110034615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165611318 | ||||||||
| FaxNumber: | 7184012888 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 GRAND CONCOURSE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104513049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185185550 | ||||||||
| FaxNumber: | 7185185111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 02/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 207405 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 207405 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 02809763 | 05 | NY | MEDICAID | 207405 | 01 | NY | NYS LICENSE | OTHER |