MEDICARE: DR. ROGER ALAN BLAKE M.D.

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	174400000X	Specialist	16881	MS
2	2086S0102X	Surgical Critical Care Physician	MC-2670	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	7887026	OTHER		AETNA

General Provider Information

NPI Number	:	1023049335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER ALAN BLAKE M.D.

Provider Business Mailing Address
First Line	:	907 E SUNFLOWER RD
Second Line	:	101
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2830
Country	:	US
Telephone Number	:	662-846-8880
Fax Number	:	662-846-8886

Provider Business Practice Location Address
First Line	:	907 E SUNFLOWER RD
Second Line	:	101
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2830
Country	:	US
Telephone Number	:	662-846-8880
Fax Number	:	662-846-8886

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	03/04/2024

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