Provider Demographics
NPI:1396003877
Name:BLYTHE, GREGORY J (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:BLYTHE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 A AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1026 A AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5036
Practice Address - Country:US
Practice Address - Phone:319-431-8450
Practice Address - Fax:319-369-7419
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-05171207P00000X
IN02004261A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000835632OtherANTHEM PIN
IN201101120Medicaid
IN264430138Medicare PIN