Provider Demographics
NPI:1013663749
Name:BLAKE MEDICAL CARE SC
Entity Type:Organization
Organization Name:BLAKE MEDICAL CARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-984-3290
Mailing Address - Street 1:1350 COUNTRY CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1029
Mailing Address - Country:US
Mailing Address - Phone:847-984-3290
Mailing Address - Fax:
Practice Address - Street 1:131 E PARK AVE STE 103
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2858
Practice Address - Country:US
Practice Address - Phone:847-984-3290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty