Provider Demographics
NPI:1225046089
Name:TAKESUE, BLAINE Y (MD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:Y
Last Name:TAKESUE
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5550 S EAST ST
Practice Address - Street 2:STE I
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1991
Practice Address - Country:US
Practice Address - Phone:317-780-4080
Practice Address - Fax:317-780-4088
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040029A207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100103460Medicaid
IN100342970Medicaid
IN274250KMedicare PIN
INP00767611Medicare PIN
INF07039Medicare UPIN
IN100342970Medicaid