Healthcare Provider Details

I. General information

NPI: 1003445115
Provider Name (Legal Business Name): BLAKE EVANS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 EXECUTIVE PARK
LOUISVILLE KY
40207-4201
US

IV. Provider business mailing address

PO BOX 21890
BELFAST ME
04915-4115
US

V. Phone/Fax

Practice location:
  • Phone: 502-855-7200
  • Fax: 502-855-7201
Mailing address:
  • Phone: 502-907-0356
  • Fax: 502-919-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number60610
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number60610
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number01096300A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: