MEDICARE: MRS. GINA RENEE BLAKE P.T.

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	7434	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	20265I4817	OTHER	GA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11816396	OTHER	GA	CAQH

General Provider Information

NPI Number	:	1053596569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GINA RENEE BLAKE P.T.

Provider Business Mailing Address
First Line	:	4754 MARTIN RD
Second Line	:	SUITE 200
City	:	FLOWERY BRANCH
State	:	GA
Zip	:	30542-3507
Country	:	US
Telephone Number	:	770-967-4377
Fax Number	:	770-967-8077

Provider Business Practice Location Address
First Line	:	4754 MARTIN RD
Second Line	:	SUITE 200
City	:	FLOWERY BRANCH
State	:	GA
Zip	:	30542-3507
Country	:	US
Telephone Number	:	770-967-4377
Fax Number	:	770-967-8077

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

Provider Enumeration Date	:	01/03/2008
Last Update Date	:	12/12/2011

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Directions to “ MRS. GINA RENEE BLAKE P.T.” Practice Location

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