Individual
DALE W BLAISE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
19 E SHAWNEE DR STE 2, MURPHYSBORO, IL 62966-7072
(618) 684-2172
(618) 687-4480
Mailing address
PO BOX 3988, CARBONDALE, IL 62902-3988
(618) 457-5200
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036065426
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036065426
—
IL
01
—
3932056
BCBS
IL
01
—
7210895
AETNA
IL
01
—
8630880
MULTI PLAN
IL
Enumeration date
02/17/2006
Last updated
08/24/2022
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