Basic Information
Provider Information | |||||||||
NPI: | 1700180072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLAIR | ||||||||
FirstName: | ROGER | ||||||||
MiddleName: | BYRON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1434 BROADRICK DR | ||||||||
Address2: |   | ||||||||
City: | DALTON | ||||||||
State: | GA | ||||||||
PostalCode: | 307203009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062785961 | ||||||||
FaxNumber: | 7065299588 | ||||||||
Practice Location | |||||||||
Address1: | 6120 ALABAMA HWY | ||||||||
Address2: |   | ||||||||
City: | RINGGOLD | ||||||||
State: | GA | ||||||||
PostalCode: | 307362804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7069356442 | ||||||||
FaxNumber: | 7069356441 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2010 | ||||||||
LastUpdateDate: | 10/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 6111 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 003119262B | 05 | GA |   | MEDICAID |