Provider Demographics
NPI:1922192947
Name:BLAKELY, MARK H (DPT,OCS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:H
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:DPT,OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MARKET ST STE 4103
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-5636
Mailing Address - Country:US
Mailing Address - Phone:828-342-7358
Mailing Address - Fax:
Practice Address - Street 1:4 MARKET ST
Practice Address - Street 2:SUITE 4103
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-5635
Practice Address - Country:US
Practice Address - Phone:828-877-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98352251X0800X
NCNC7217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC650016318OtherRR MEDICARE #
NCB8364OtherMEDCOST #
NC078RCOtherBLUE CROSS BLUE SHIELD #
NC7211278Medicaid
NC2502490Medicare ID - Type Unspecified