Healthcare Provider Details

I. General information

NPI: 1023049335
Provider Name (Legal Business Name): ROGER ALAN BLAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 E SUNFLOWER RD 101
CLEVELAND MS
38732-2830
US

IV. Provider business mailing address

907 E SUNFLOWER RD 101
CLEVELAND MS
38732-2830
US

V. Phone/Fax

Practice location:
  • Phone: 662-846-8880
  • Fax: 662-846-8886
Mailing address:
  • Phone: 662-846-8880
  • Fax: 662-846-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number16881
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMC-2670
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: