MEDICARE: GAYLE B BLAKE P.A.C.

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	363A00000X	Physician Assistant		IL

General Provider Information

NPI Number	:	1487693461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAYLE B BLAKE P.A.C.

Provider Business Mailing Address
First Line	:	467 W DEMING PL
Second Line	:	SUITE 500
City	:	CHICAGO
State	:	IL
Zip	:	60614-1881
Country	:	US
Telephone Number	:	773-388-6390
Fax Number	:	773-477-9712

Provider Business Practice Location Address
First Line	:	467 W DEMING PL
Second Line	:	SUITE 500
City	:	CHICAGO
State	:	IL
Zip	:	60614-1881
Country	:	US
Telephone Number	:	773-388-6390
Fax Number	:	773-477-9712

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

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

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