Provider Demographics
NPI:1730207440
Name:JEFFREY M. BLAKE MD, INC.
Entity type:Organization
Organization Name:JEFFREY M. BLAKE MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-646-8569
Mailing Address - Street 1:141 W. 22ND ST.
Mailing Address - Street 2:SUITE 309
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4389
Mailing Address - Country:US
Mailing Address - Phone:765-646-8569
Mailing Address - Fax:765-622-9708
Practice Address - Street 1:141 W. 22ND ST.
Practice Address - Street 2:SUITE 309
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4389
Practice Address - Country:US
Practice Address - Phone:765-646-8569
Practice Address - Fax:765-622-9708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN234990Medicare ID - Type Unspecified