Provider Demographics
NPI:1982654133
Name:BLASKE, GREGORY L (PT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:BLASKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:3385 DEXTER CT STE 203
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-332-9312
Practice Address - Fax:563-332-9316
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01817225100000X
IL070-005511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01817OtherIOWA PT LICENSE NUMBER
IL070-005511OtherILLINOIS PT LICENSE NO.
IA01817OtherIOWA PT LICENSE NUMBER
IL$$$$$$$$$001Medicaid