Basic Information
| Provider Information | |||||||||
| NPI: | 1104802735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2700 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105772547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146075730 | ||||||||
| FaxNumber: | 9144571195 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106042901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146826470 | ||||||||
| FaxNumber: | 9146815245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 04/16/2018 | ||||||||
| 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 | 208800000X | 043121 | CT | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 235484 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 4C8926 | 01 | NY | HEALTH NET | OTHER | 1099112 | 01 | NY | GHIPPO | OTHER | 235484 | 01 | NY | CONNECTICARE | OTHER | 235484 | 01 | NY | HIP | OTHER | 133884168 | 01 | NY | MULTIPLAN | OTHER | 1785846 | 01 | NY | CIGNA SPECIALTY | OTHER | P3599637 | 01 | NY | OXFORD | OTHER | 133884168 | 01 | NY | POMCO | OTHER | 000000088488 | 01 | NY | GHI HMO | OTHER | 133884168 | 01 | NY | EMPIRE STATE PLAN (NYS) | OTHER | 133884168 | 01 | NY | PHCS | OTHER | 2527752 | 01 | NY | UNITED HEALTH CARE | OTHER | 39R431 | 01 | NY | BLUE CROSS ALL PLANS | OTHER | 7786694 | 01 | NY | AETNA NON HMO | OTHER | 133884168 | 01 | NY | BEECH STREET | OTHER | 133884168 | 05 | NY | MEDICAID | 3918982 | 01 | NY | AETNA HMO SPECIALTY CARE | OTHER |