Provider Demographics
NPI:1174671820
Name:BLAKE, GEORGE E (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:E
Last Name:BLAKE
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 1:4760 E GALBRAITH RD STE 205
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-6704
Mailing Address - Country:US
Mailing Address - Phone:513-985-0741
Mailing Address - Fax:
Practice Address - Street 1:4760 E GALBRAITH RD STE 205
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236
Practice Address - Country:US
Practice Address - Phone:513-985-0741
Practice Address - Fax:513-985-0748
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35130836207RA0001X, 207RC0000X
IN01068537A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200992360Medicaid
FLHQ800ZOtherPTAN
IN200992360Medicaid