Healthcare Provider Details

I. General information

NPI: 1578513701
Provider Name (Legal Business Name): MICHAEL JOSEPH BLAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 ALASKA FRONTAGE RD
BELGRADE MT
59714-7909
US

IV. Provider business mailing address

915 HIGHLAND BLVD ATTN PFS CREDENTIALING
BOZEMAN MT
59715-6902
US

V. Phone/Fax

Practice location:
  • Phone: 406-414-3334
  • Fax:
Mailing address:
  • Phone: 406-414-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12120
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: