Basic Information
| Provider Information | |||||||||
| NPI: | 1235147455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAISDELL | ||||||||
| FirstName: | GREG | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20308 | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767020308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547514880 | ||||||||
| FaxNumber: | 2547514885 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 LONDONDERRY DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767127915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547514880 | ||||||||
| FaxNumber: | 2547514885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | H7904 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 260049492 | 01 | TX | MEDICARE RAILROAD | OTHER | 113785305 | 05 | TX | MEDICAID | 084249401 | 05 | TX | MEDICAID | 00N59X | 01 | TX | BLUE CROSS AND BLUE SHIEL | OTHER | 8246K8 | 01 | TX | BLUE CROSS AND BLUE SHIEL | OTHER | 040482401 | 05 | TX | MEDICAID |