Provider Demographics
NPI:1093798134
Name:ANDERSON, BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 RED OAK PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7346
Mailing Address - Country:US
Mailing Address - Phone:314-591-3417
Mailing Address - Fax:
Practice Address - Street 1:1344 RED OAK PLANTATION DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-7346
Practice Address - Country:US
Practice Address - Phone:314-591-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009013290207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-13048OtherMEDICA
MNMH9041023739OtherPREFERRED ONE
MO1093798134Medicaid
MN150459Medicaid
MN67Q18ANOtherBLUE CROSS/BLUE PLUS
MNA035OtherCHAMPUS
MN16690100Medicaid
MN1019018OtherARAZ
MN7291OtherAVERA
MN21955OtherSIOUX VALLEY HEALTH PLANS
MNHP30702OtherHEALTHPARTNERS
MN01-13048OtherMEDICA
MO147480057Medicare PIN
MN67Q18ANOtherBLUE CROSS/BLUE PLUS
MN150459Medicaid
MNHP30702OtherHEALTHPARTNERS
MO1093798134Medicaid