1184607038 NPI number — MICHAEL C BLAKLEY JR. MD

Table of content: MICHAEL C BLAKLEY JR. MD (NPI 1184607038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184607038 NPI number — MICHAEL C BLAKLEY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKLEY
Provider First Name:
MICHAEL
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1184607038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 RILEY HOSPITAL DR
Provider Second Line Business Practice Location Address:
RR 307
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-274-2172
Provider Business Practice Location Address Fax Number:
317-278-3031
Provider Enumeration Date:
11/23/2005

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: 207R00000X , with the licence number:  01060351A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 01060351A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 01060351A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0216X , with the licence number: 01060351A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200903650 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000774382 . This is a "ANTHEM PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000769478 . This is a "ANTHEM PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01339696 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com