MEDICARE: BLAKE MEDICAL CARE SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1013663749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAKE MEDICAL CARE SC

Provider Business Mailing Address
First Line	:	1350 COUNTRY CT
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1029
Country	:	US
Telephone Number	:	847-984-3290
Fax Number	:

Provider Business Practice Location Address
First Line	:	131 E PARK AVE STE 103
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-2858
Country	:	US
Telephone Number	:	847-984-3290
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KATHERINE BLAKE
Credential	:	DO
Telephone Number	:	847-984-3290

Provider Enumeration Date	:	02/22/2022
Last Update Date	:	02/22/2022

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Directions to “BLAKE MEDICAL CARE SC ” Practice Location

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