Basic Information
| Provider Information | |||||||||
| NPI: | 1689864233 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAISDELL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301C US ROUTE 1 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 335 BRIGHTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076628600 | ||||||||
| FaxNumber: | 2076628668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 10/12/2015 | ||||||||
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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 | 207X00000X | MD20727 | ME | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | ML20008868 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 207X00000X | ME112516 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 16000 | NH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 14L3J | 01 | FL | BC/BS | OTHER | 3086827 | 05 | NH | MEDICAID | PENDING | 01 | FL | AETNA | OTHER | PENDING | 01 | FL | CIGNA | OTHER | 1689864233 | 05 | FL | MEDICAID |