Provider Demographics
NPI:1811027980
Name:BUETOW, BLAKE SCOTT (DPT)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:SCOTT
Last Name:BUETOW
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 COUNTY ROAD E E STE 120
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5191
Mailing Address - Country:US
Mailing Address - Phone:651-241-1464
Mailing Address - Fax:
Practice Address - Street 1:1155 COUNTY ROAD E E STE 120
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-5191
Practice Address - Country:US
Practice Address - Phone:651-241-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN75872251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
052N1BUOtherBLUE CROSS BLUE SHIELD
MN765105000Medicaid