MEDICARE: ROBERT BLAKER

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	390200000X	Student in an Organized Health Care Education/Training Program	S10709	AL

General Provider Information

NPI Number	:	1659766533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT BLAKER

Provider Business Mailing Address
First Line	:	68 HUDSON DR
Second Line	:
City	:	BOAZ
State	:	AL
Zip	:	35956-3522
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	68 HUDSON DR
Second Line	:
City	:	BOAZ
State	:	AL
Zip	:	35956-3522
Country	:	US
Telephone Number	:	256-558-6589
Fax Number	:

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

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	03/30/2015

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