Provider Demographics
NPI:1770627234
Name:BLAKE WELLING, MD PC
Entity Type:Organization
Organization Name:BLAKE WELLING, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WELLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-387-6520
Mailing Address - Street 1:4403 HARRISON BLVD
Mailing Address - Street 2:SUITE 1815
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-6520
Mailing Address - Fax:801-387-6525
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 1815
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-6520
Practice Address - Fax:801-387-6525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT97-344917-1205207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528113182005Medicaid
UTG61593Medicare UPIN