MEDICARE: BLAKES ANESTHESIA SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist

General Provider Information

NPI Number	:	1487132445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAKES ANESTHESIA SERVICES, INC.

Provider Business Mailing Address
First Line	:	400 10TH ST E
Second Line	:
City	:	WACONIA
State	:	MN
Zip	:	55387-4552
Country	:	US
Telephone Number	:	888-209-0305
Fax Number	:	952-442-3620

Provider Business Practice Location Address
First Line	:	2115 E 7TH ST STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-3300
Country	:	US
Telephone Number	:	888-209-0305
Fax Number	:	952-442-3620

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHERYL YVETTE BLAKE
Credential	:	CRNA
Telephone Number	:	215-681-8661

Provider Enumeration Date	:	08/01/2018
Last Update Date	:	08/24/2019

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