Healthcare Provider Details

I. General information

NPI: 1669293890
Provider Name (Legal Business Name): MR. JUSTIN DAVID BLYTHE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 625
PARK RIDGE IL
60068-1137
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-4088
  • Fax: 847-627-8700
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License Number041548967
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-032573
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-032573
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: