MEDICARE: DR. WYATT KENNY BLAKE MD

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	207Q00000X	Family Medicine Physician	047702	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	080176614	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	843785	OTHER	GA	BCBS OF GEORGIA
4	047702	OTHER	GA	GA LICENSE

General Provider Information

NPI Number	:	1548263064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WYATT KENNY BLAKE MD

Provider Business Mailing Address
First Line	:	1005 BOULDER DR
Second Line	:
City	:	GRAY
State	:	GA
Zip	:	31032-6141
Country	:	US
Telephone Number	:	478-621-2100
Fax Number	:	478-744-0481

Provider Business Practice Location Address
First Line	:	1005 BOULDER DR
Second Line	:
City	:	GRAY
State	:	GA
Zip	:	31032
Country	:	US
Telephone Number	:	478-621-2100
Fax Number	:	478-744-0481

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2005
Last Update Date	:	07/17/2019

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