Provider Demographics
NPI:1902803869
Name:BLEVINS, WAYNE JR
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:BLEVINS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033-1166
Mailing Address - Country:US
Mailing Address - Phone:217-839-4491
Mailing Address - Fax:205-313-5299
Practice Address - Street 1:11574 RT 108
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-4091
Practice Address - Country:US
Practice Address - Phone:217-854-4319
Practice Address - Fax:217-854-2765
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2642207P00000X
IL085004267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4077ZMedicaid
FL606478700OtherDEPT OF LABOR
FL96317OtherHEALTH PARTNERS
FL290049100Medicare ID - Type UnspecifiedEMERALD COAST MEDICAL#
FL96317OtherHEALTH PARTNERS