Healthcare Provider Details

I. General information

NPI: 1760605455
Provider Name (Legal Business Name): ROBERT ERNEST BLEASE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2177 W IRONWOOD CENTER DR
COEUR D ALENE ID
83814-2639
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6111
  • Fax: 208-625-6112
Mailing address:
  • Phone: 208-625-6111
  • Fax: 208-625-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMED-PHYS-LIC-69984
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberME108720
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM-16171
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: