Provider Demographics
NPI:1912775602
Name:BLAINE, JOHN M (CPRS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:BLAINE
Suffix:
Gender:M
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 LANCASTER PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-1511
Mailing Address - Country:US
Mailing Address - Phone:302-278-0026
Mailing Address - Fax:302-278-0047
Practice Address - Street 1:3700 LANCASTER PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-1511
Practice Address - Country:US
Practice Address - Phone:302-278-0026
Practice Address - Fax:302-278-0047
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2144175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist