1841257482 NPI number — DR. GREGORY HAROLD BLAKE MD, MPH

Table of content: DR. GREGORY HAROLD BLAKE MD, MPH (NPI 1841257482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841257482 NPI number — DR. GREGORY HAROLD BLAKE MD, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
GREGORY
Provider Middle Name:
HAROLD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MPH
Provider Gender Code:
M

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:
1841257482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1924 ALCOA HWY
Provider Second Line Business Mailing Address:
U-67
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37920-1511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-544-9352
Provider Business Mailing Address Fax Number:
865-544-9314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1924 ALCOA HWY
Provider Second Line Business Practice Location Address:
U-100
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37920-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-544-9351
Provider Business Practice Location Address Fax Number:
865-544-9314
Provider Enumeration Date:
04/27/2006

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: 207Q00000X , with the licence number:  26558 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3092066 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3523237 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 100011282 . This is a "PHP TENNCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5766020 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 01-41085 . This is a "UNITED HEATLH CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 080100419 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1689631137 . This is a "GROUP NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3023731 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0191 . This is a "JOHN DEERE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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