Healthcare Provider Details

I. General information

NPI: 1750178190
Provider Name (Legal Business Name): BLAKE CHILDRESS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 06/12/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 N BROADWAY ST
CHICAGO IL
60660-2538
US

IV. Provider business mailing address

10403 PARMER CIR
FISHERS IN
46038-5782
US

V. Phone/Fax

Practice location:
  • Phone: 773-564-9206
  • Fax:
Mailing address:
  • Phone: 317-363-5420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.011277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: