Provider Demographics
NPI:1003931437
Name:BLAU, GREGORY MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:BLAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:W222N2728 STONEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1035
Mailing Address - Country:US
Mailing Address - Phone:262-547-2528
Mailing Address - Fax:262-783-9992
Practice Address - Street 1:14625 W LISBON RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-1626
Practice Address - Country:US
Practice Address - Phone:262-783-5010
Practice Address - Fax:262-783-9992
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT61519Medicare UPIN