Healthcare Provider Details

I. General information

NPI: 1093800245
Provider Name (Legal Business Name): SIDNEY ALLEN BLAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N COX ST STE 6
ASHEBORO NC
27203-5514
US

IV. Provider business mailing address

PO BOX 4577
ASHEBORO NC
27204-4577
US

V. Phone/Fax

Practice location:
  • Phone: 336-633-1937
  • Fax: 336-633-1942
Mailing address:
  • Phone: 336-633-1937
  • Fax: 336-633-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9400725
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01081509A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: