MEDICARE: DR. BLAKE JORDAN GRIDER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	01073655A	IN
2	207P00000X	Emergency Medicine Physician	35.154600	OH
3	207P00000X	Emergency Medicine Physician	ME180410	FL

General Provider Information

NPI Number	:	1891089538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE JORDAN GRIDER M.D.

Provider Business Mailing Address
First Line	:	4420 N PENNSYLVANIA ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1728
Country	:	US
Telephone Number	:	317-925-1467
Fax Number	:	317-925-9850

Provider Business Practice Location Address
First Line	:	2001 W 86TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260
Country	:	US
Telephone Number	:	317-338-2345
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2011
Last Update Date	:	04/13/2026

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