=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932194784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARSON CURTIS BLAKE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2005
-----------------------------------------------------
Last Update Date | 05/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 N. MAIN
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-682-6862
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 N. MAIN
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-682-6862
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 7066
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------