1295959310 NPI number — BLAKE FAMILY MEDICINE PLLC

Table of content: (NPI 1295959310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295959310 NPI number — BLAKE FAMILY MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLAKE FAMILY MEDICINE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1295959310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHALLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28459-3206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-754-4545
Provider Business Mailing Address Fax Number:
910-754-4794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4704 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHALLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28470-1880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-754-4545
Provider Business Practice Location Address Fax Number:
910-754-4794
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-754-4545

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  10868 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363A00000X , with the licence number: 103290 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363A00000X , with the licence number: 103296 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 5902868 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017W4 . This is a "BCBS GRP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 55210 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 185616 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 858799 . This is a "UHC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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