Provider Demographics
NPI:1942304027
Name:BLAINE, JAMES ELDRIDGE JR (DPM)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ELDRIDGE
Last Name:BLAINE
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4839
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-4839
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:355 E CAMPUS VIEW BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-5616
Practice Address - Country:US
Practice Address - Phone:614-987-1424
Practice Address - Fax:855-252-4451
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003408213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2553062Medicaid
OH9354431OtherMEDICARE GROUP #
OH9354431OtherMEDICARE GROUP #
V05646Medicare UPIN