MEDICARE: BLAKE ALLEN LITTLE, M.D., L.L.C.

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	174400000X	Specialist	40672	TN
2	174400000X	Specialist	58363	GA
3	174400000X	Specialist	N-8113	AR
4	174400000X	Specialist	036-106221	IL
5	174400000X	Specialist	04-25029	KS
6	174400000X	Specialist	1170	MN
7	174400000X	Specialist	16264	OK
8	174400000X	Specialist	R4J98	MO

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	0000205533	OTHER	KS	KS BLUE CROSS
3	7404	OTHER	MO	MO BLUE CROSS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	55425	OTHER	AR	ARKANSAS BLUE CROSS
6	150325	OTHER	MO	MO BLUE CROSS
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659480713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAKE ALLEN LITTLE, M.D., L.L.C.

Provider Business Mailing Address
First Line	:	5612 E 117TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-8528
Country	:	US
Telephone Number	:	918-510-0129
Fax Number	:	918-296-5172

Provider Business Practice Location Address
First Line	:	5612 E 117TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137
Country	:	US
Telephone Number	:	918-510-0129
Fax Number	:	918-296-5172

Authorized Official
Title or Position	:	MGMR
Name	:	MELISSA K QUALLS
Credential	:
Telephone Number	:	918-510-0129

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	05/22/2018

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