Basic Information
| Provider Information | |||||||||
| NPI: | 1962498378 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BLAIR | ||||||||
| FirstName: | GARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 GORE ST | ||||||||
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| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021411131 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 GARLAND ST | ||||||||
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| City: | EVERETT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021495066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176651000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 06/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 79479 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3128369 | 05 | MA | MEDICAID |