MEDICARE: MARY L BLAKE REEVES

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	363L00000X	Nurse Practitioner	068911	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1710937073	OTHER	MO	NATIONAL PROVIDER IDENTIFIER
4	11646789	OTHER	MO	CAQH

General Provider Information

NPI Number	:	1710937073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY L BLAKE REEVES

Provider Business Mailing Address
First Line	:	5535 DELMAR BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-3005
Country	:	US
Telephone Number	:	314-879-6300
Fax Number	:	314-879-6372

Provider Business Practice Location Address
First Line	:	4626 LEE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-2431
Country	:	US
Telephone Number	:	314-385-7726
Fax Number	:

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

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	09/19/2011

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