Provider Demographics
NPI:1689864233
Name:BLAISDELL, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BLAISDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 BRIGHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2363
Practice Address - Country:US
Practice Address - Phone:207-662-8600
Practice Address - Fax:207-662-8668
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD20727207X00000X
WAML20008868208600000X
FLME112516207X00000X
NH16000207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14L3JOtherBC/BS
NH3086827Medicaid
FLPENDINGOtherAETNA
FLPENDINGOtherCIGNA
FL1689864233Medicaid
NH003436601Medicare PIN
MEE400245824Medicare PIN
FLGE461ZMedicare PIN
MEE400245914Medicare PIN