MEDICARE: BEVAN D BLAKE PT, 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	344859-2401	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	CJ9402	OTHER	UT	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	64-00731	OTHER	UT	UNITED HEALTHCARE
2	68963	OTHER	UT	PEHP
3	870388269BR1	OTHER	UT	EDUCATORS MUTUAL
5	34485924000001	OTHER	UT	BLUE CROSS BLUE SHIELD
6	5417	OTHER	UT	DMBA

General Provider Information

NPI Number	:	1114928868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVAN D BLAKE PT, DPT

Provider Business Mailing Address
First Line	:	370 E SOUTH TEMPLE
Second Line	:	#250
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1206
Country	:	US
Telephone Number	:	801-512-2656
Fax Number	:	801-906-0336

Provider Business Practice Location Address
First Line	:	370 E SOUTH TEMPLE
Second Line	:	#250
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1206
Country	:	US
Telephone Number	:	801-512-2656
Fax Number	:	801-906-0336

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

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	10/10/2012

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Directions to “ BEVAN D BLAKE PT, DPT” Practice Location

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