Provider Demographics
NPI:1073735304
Name:BLAKE, MELANIE BLACK (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:BLACK
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 FERN TRL
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-3167
Mailing Address - Country:US
Mailing Address - Phone:205-999-0232
Mailing Address - Fax:
Practice Address - Street 1:1008 EXECUTIVE DR STE 104
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3992
Practice Address - Country:US
Practice Address - Phone:423-497-5363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44821207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP00749338OtherRAILROAD MEDICARE