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NPI Code Detail

MEDICARE: JEROME M BLAKE MD

MEDICARE: JEROME M BLAKE MD
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
12080P0008XPediatric Neurodevelopmental Disabilities Physician2228SD

General Provider Information

NPI Number : 1699760546
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEROME M BLAKE MD
Provider Business Mailing Address
First Line : PO BOX 5074
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57117-5074
Country : US
Telephone Number : 605-328-7180
Fax Number : 605-328-7177
Provider Business Practice Location Address
First Line : 1600 W 22ND ST
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57105-1521
Country : US
Telephone Number : 605-312-1000
Fax Number : 605-312-1001
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/16/2005
Last Update Date : 03/13/2015

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