Basic Information
| Provider Information | |||||||||
| NPI: | 1770826372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632801 | ||||||||
| FaxNumber: | 5039632825 | ||||||||
| Practice Location | |||||||||
| Address1: | 24900 SE STARK ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039358088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2013 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD191957 | OR | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 500760980 | 05 | OR | MEDICAID |