Healthcare Provider Details

I. General information

NPI: 1730207440
Provider Name (Legal Business Name): JEFFREY M. BLAKE MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W. 22ND ST. SUITE 309
ANDERSON IN
46016-4389
US

IV. Provider business mailing address

141 W. 22ND ST. SUITE 309
ANDERSON IN
46016-4389
US

V. Phone/Fax

Practice location:
  • Phone: 765-646-8569
  • Fax: 765-622-9708
Mailing address:
  • Phone: 765-646-8569
  • Fax: 765-622-9708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. JEFFREY M. BLAKE
Title or Position: OWNER
Credential: M.D.
Phone: 765-646-8569