Basic Information
| Provider Information | |||||||||
| NPI: | 1447465844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAGRAVE | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 6TH ST SW | ||||||||
| Address2: | MEDICAL EDUCATION | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303634899 | ||||||||
| FaxNumber: | 3305805513 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 6TH ST SW | ||||||||
| Address2: | MEDICAL EDUCATION | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303634899 | ||||||||
| FaxNumber: | 3305805513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 08/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301095822 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1447465844 | 05 | MI | MEDICAID |