Healthcare Provider Details

I. General information

NPI: 1225046089
Provider Name (Legal Business Name): BLAINE Y TAKESUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 S EAST ST STE I
INDIANAPOLIS IN
46227-1991
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 130
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-780-4080
  • Fax: 317-780-4088
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01040029A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01040029A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: