MEDICARE: DR. KATHERINE M BLAKE D.O.

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	207Q00000X	Family Medicine Physician	125-061735	IL
2	207Q00000X	Family Medicine Physician	64086	WI
3	207QB0002X	Obesity Medicine (Family Medicine) Physician	036136377	IL
4	207Q00000X	Family Medicine Physician	036136377	IL

General Provider Information

NPI Number	:	1225304322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHERINE M BLAKE D.O.

Provider Business Mailing Address
First Line	:	131 E PARK AVE STE 103
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-2858
Country	:	US
Telephone Number	:	847-984-3290
Fax Number	:	847-255-2015

Provider Business Practice Location Address
First Line	:	131 E PARK AVE STE 103
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-2858
Country	:	US
Telephone Number	:	847-984-3290
Fax Number	:	847-255-2015

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

Provider Enumeration Date	:	03/22/2012
Last Update Date	:	05/03/2022

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