MEDICARE: MICHAEL BLAKE DPT

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	225100000X	Physical Therapist	2305215230	VA

General Provider Information

NPI Number	:	1043948060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL BLAKE DPT

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:	630-575-6200
Fax Number	:	410-648-4878

Provider Business Practice Location Address
First Line	:	2925 POLO PKWY
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23113-1453
Country	:	US
Telephone Number	:	804-794-7587
Fax Number	:	804-794-4560

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

Provider Enumeration Date	:	08/09/2022
Last Update Date	:	05/19/2026

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