Healthcare Provider Details

I. General information

NPI: 1477849602
Provider Name (Legal Business Name): BLAKE WILLIAM BARNES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR DCO58.00
COLUMBIA MO
65201-5276
US

IV. Provider business mailing address

1 HOSPITAL DR DCO58.00
COLUMBIA MO
65201-5276
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4438
  • Fax: 573-884-9992
Mailing address:
  • Phone: 573-882-4438
  • Fax: 573-884-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2011019428
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2011019428
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: