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NPI Code Detail

MEDICARE: MR. BLAKE EDWARD SIDLECK PA

MEDICARE: MR. BLAKE EDWARD SIDLECK PA
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
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1831088343
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BLAKE EDWARD SIDLECK PA
Provider Business Mailing Address
First Line : 5479 GLENRIDGE DR APT 4404
Second Line :
City : ATLANTA
State : GA
Zip : 30342-1340
Country : US
Telephone Number : 484-951-3217
Fax Number :
Provider Business Practice Location Address
First Line : 550 PEACHTREE ST NE STE 1700
Second Line :
City : ATLANTA
State : GA
Zip : 30308-2262
Country : US
Telephone Number : 484-951-3217
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2025
Last Update Date : 06/30/2025

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Directions to “ MR. BLAKE EDWARD SIDLECK PA” Practice Location

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