Provider Demographics
NPI:1689084477
Name:PHIPPS, BLAKE GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:GORDON
Last Name:PHIPPS
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 1:4951 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-2090
Mailing Address - Country:US
Mailing Address - Phone:785-841-6540
Mailing Address - Fax:785-841-3305
Practice Address - Street 1:4951 W 18TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047
Practice Address - Country:US
Practice Address - Phone:785-841-6540
Practice Address - Fax:785-841-3305
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0441094207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201205020AMedicaid