Healthcare Provider Details

I. General information

NPI: 1760779458
Provider Name (Legal Business Name): BLAKE BAILEY ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 MIAMI VALLEY DR STE 500
CENTERVILLE OH
45459-4780
US

IV. Provider business mailing address

6680 POE AVE STE 200
DAYTON OH
45414-2855
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-1622
  • Fax: 937-245-6308
Mailing address:
  • Phone: 937-280-8400
  • Fax: 937-245-6330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.059643
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01078386A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35133214
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: