MEDICARE: MARCIA ELLEN BLAKE O.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	152W00000X	Optometrist	046-006808	IL
2	152W00000X	Optometrist	1664	MN

General Provider Information

NPI Number	:	1053490219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCIA ELLEN BLAKE O.D.

Provider Business Mailing Address
First Line	:	10225 S OAKLEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1915
Country	:	US
Telephone Number	:	773-233-3892
Fax Number	:

Provider Business Practice Location Address
First Line	:	1903 W 103RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2624
Country	:	US
Telephone Number	:	773-233-7799
Fax Number	:

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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