Provider Demographics
NPI:1962442723
Name:BLAKELY, GREG M (MD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:M
Last Name:BLAKELY
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 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:
Practice Address - Street 1:15 REGIONAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8850
Practice Address - Country:US
Practice Address - Phone:910-295-5511
Practice Address - Fax:910-255-4382
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01364OtherSC MEDICAID PROVIDER#
NC182244OtherMEDCOST PROVIDER#
NCFH1020395OtherFIRSTCAROLINACARE PROV.#
NC0404211OtherEVERCARE
NC140HMOtherBC/BS NC PROVIDER#
NC5902414Medicaid
NCP00255691OtherPALMETTO GBA PROVIDER#
NC0404211OtherEVERCARE
I40044Medicare UPIN