Provider Demographics
NPI:1538663463
Name:BLAKELY, GREGORY M
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:M
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 NORTH 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995
Mailing Address - Country:US
Mailing Address - Phone:618-658-8144
Mailing Address - Fax:618-658-9146
Practice Address - Street 1:811 NORTH 1ST STREET
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995
Practice Address - Country:US
Practice Address - Phone:618-658-8144
Practice Address - Fax:618-658-9146
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.005246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist