Provider Demographics
NPI:1447327564
Name:BLAESING, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BLAESING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1688 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4608
Mailing Address - Country:US
Mailing Address - Phone:770-995-2379
Mailing Address - Fax:770-995-2385
Practice Address - Street 1:1688 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4608
Practice Address - Country:US
Practice Address - Phone:770-995-2379
Practice Address - Fax:770-995-2385
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002459174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10037741Medicaid
GA306071Medicaid