Basic Information
| Provider Information | |||||||||
| NPI: | 1679718563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEVINS | ||||||||
| FirstName: | GRAIG | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 BRADDOCK LN | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080965140 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 COOPER PLZ | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2008 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 25MB0359000 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | OS12408 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.