1225089857 NPI number — ANNE B BLAKE NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225089857 NPI number — ANNE B BLAKE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
ANNE
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225089857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1259
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29021-1259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-713-8350
Provider Business Mailing Address Fax Number:
803-713-8433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 DEWITT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUGOFF
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29078-9069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-438-7566
Provider Business Practice Location Address Fax Number:
803-438-4371
Provider Enumeration Date:
05/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1450 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500022911 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: B5703 . This is a "MEDCOST PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: NP0429 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".