Healthcare Provider Details

I. General information

NPI: 1306131453
Provider Name (Legal Business Name): BLAKE JOSEPH NEWMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-5000
  • Fax:
Mailing address:
  • Phone: 314-362-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2011015246
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number9349026-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: