Basic Information
| Provider Information | |||||||||
| NPI: | 1386632313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEBEA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HOUGHTON AVE. | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895836800 | ||||||||
| FaxNumber: | 9895836955 | ||||||||
| Practice Location | |||||||||
| Address1: | 912 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486012564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187443523 | ||||||||
| FaxNumber: | 9187443463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 28809 | OK | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 4301111451 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 28809 | OK | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 4301111451 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0828297 | 05 | OH | MEDICAID | 0016666360006 | 05 | PA | MEDICAID |