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General NPI Number Information
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NPI Number | 1902803869
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Entity Type | Individual
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Provider Name | WAYNE BLEVINS JR.
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Gender | Male
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Dates
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Enumeration Date | 07/06/2005
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Last Update Date | 04/23/2015
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Provider Practice Location Address
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Address Line | 11574 RT 108
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City | CARLINVILLE
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State | IL
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Zip | 62626-4091
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Country | US
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Telephone | 217-854-4319
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Fax | 217-854-2765
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Provider Business Mailing Address
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Address Line | 715 BROADWAY ST
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City | GILLESPIE
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State | IL
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Zip | 62033-1166
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Country | US
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Telephone | 217-839-4491
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Fax | 205-313-5299
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | PA2642
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085004267
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License Number State | IL
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