Provider Demographics
NPI:1083902837
Name:BLAKE R BURCHETT
Entity Type:Organization
Organization Name:BLAKE R BURCHETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-886-8466
Mailing Address - Street 1:535 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1278
Mailing Address - Country:US
Mailing Address - Phone:606-886-8466
Mailing Address - Fax:606-886-0250
Practice Address - Street 1:535 N LAKE DR
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1278
Practice Address - Country:US
Practice Address - Phone:606-886-8466
Practice Address - Fax:606-886-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty