1942304027 NPI number — JAMES ELDRIDGE BLAINE JR. DPM

Table of content: JAMES ELDRIDGE BLAINE JR. DPM (NPI 1942304027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942304027 NPI number — JAMES ELDRIDGE BLAINE JR. DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAINE
Provider First Name:
JAMES
Provider Middle Name:
ELDRIDGE
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942304027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4839
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48099-4839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-824-6600
Provider Business Mailing Address Fax Number:
855-618-6655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 E CAMPUS VIEW BLVD
Provider Second Line Business Practice Location Address:
SUITE 175
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43235-5616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-987-1424
Provider Business Practice Location Address Fax Number:
855-252-4451
Provider Enumeration Date:
09/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  36003408 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2553062 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9354431 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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