Healthcare Provider Details

I. General information

NPI: 1356083497
Provider Name (Legal Business Name): ANDREW CECIL BLAKE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2022
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CASS AVE
WOONSOCKET RI
02895-4731
US

IV. Provider business mailing address

150 E WYNNEWOOD RD
WYNNEWOOD PA
19096-1547
US

V. Phone/Fax

Practice location:
  • Phone: 401-769-4100
  • Fax:
Mailing address:
  • Phone: 302-632-5128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC1-0028930
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: