Healthcare Provider Details

I. General information

NPI: 1639739030
Provider Name (Legal Business Name): MARK F BLAKE MD, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 N PORT WASHINGTON RD
MILWAUKEE WI
53217-4902
US

IV. Provider business mailing address

5201 N PORT WASHINGTON RD
MILWAUKEE WI
53217-4902
US

V. Phone/Fax

Practice location:
  • Phone: 414-963-0500
  • Fax: 414-755-0743
Mailing address:
  • Phone: 414-963-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK F BLAKE
Title or Position: PRESIDENT
Credential: MD
Phone: 414-963-0500