Provider Demographics
NPI:1669293890
Name:BLYTHE, JUSTIN DAVID JR
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DAVID
Last Name:BLYTHE
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:1875 DEMPSTER ST STE 625
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1137
Practice Address - Country:US
Practice Address - Phone:847-723-4088
Practice Address - Fax:847-627-8700
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041548967163WN0800X
IL209-032573363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner