Provider Demographics
NPI:1134314107
Name:PUGH, BLAKE ARTHUR (PT)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ARTHUR
Last Name:PUGH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12220 BIRMINGHAM HWY BLDG 10, STE C
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004
Mailing Address - Country:US
Mailing Address - Phone:770-686-3700
Mailing Address - Fax:
Practice Address - Street 1:12220 BIRMINGHAM HWY BLDG 10, STE C
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004
Practice Address - Country:US
Practice Address - Phone:770-686-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT9191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7336OtherMEDICARE GROUP #