Healthcare Provider Details

I. General information

NPI: 1043897051
Provider Name (Legal Business Name): NICHOLAS BLAKE GREGORY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 09/28/2026
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TRINITY HEALTH IHA MEDICAL GROUP PALLIATIVE CARE 5301 MCAULEY DRIVE SUITE 2119
YPSILANTI MI
48197
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-7255
  • Fax:
Mailing address:
  • Phone: 734-747-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101027953
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101027953
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number5101027953
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: