Basic Information
| Provider Information | |||||||||
| NPI: | 1689992760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852751616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854632940 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2010 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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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 | 207P00000X | D75596 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 05 | NY | MEDICAID |