Healthcare Provider Details

I. General information

NPI: 1366917163
Provider Name (Legal Business Name): BLAKE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WOODLAND RD STE 318
STONEHAM MA
02180-1713
US

IV. Provider business mailing address

36 CENTRE LN
MILTON MA
02186-3912
US

V. Phone/Fax

Practice location:
  • Phone: 617-939-1602
  • Fax: 458-201-6005
Mailing address:
  • Phone: 718-541-1864
  • Fax: 458-201-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SARAH BLAKE
Title or Position: PRESIDENT
Credential: MD
Phone: 718-541-1864