Provider Demographics
NPI:1265411896
Name:BLAKE, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-8487
Mailing Address - Fax:
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-8487
Practice Address - Fax:614-293-8153
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.053889207L00000X
OH35-053889207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10826581OtherCAQH
OH2016437Medicaid
OHE88301Medicare UPIN
OH2016437Medicaid