Healthcare Provider Details

I. General information

NPI: 1164688859
Provider Name (Legal Business Name): BLAKE AUSTIN HAMBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 12/16/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

5355 PERSHING AVE APT 2D
SAINT LOUIS MO
63112-1784
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8000
  • Fax:
Mailing address:
  • Phone: 314-600-7885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2008017206
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: