Healthcare Provider Details

I. General information

NPI: 1285457606
Provider Name (Legal Business Name): BLAKE ASHLEY GRAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

400 N 9TH ST # 4A
SPRINGFIELD IL
62702-5310
US

IV. Provider business mailing address

400 N 9TH ST # 4A
SPRINGFIELD IL
62702-5310
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-4779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125085065
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: