Provider Demographics
NPI:1184607038
Name:BLAKLEY, MICHAEL C JR (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:BLAKLEY
Suffix:JR
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RR 307
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-2172
Practice Address - Fax:317-278-3031
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060351A207R00000X, 207RR0500X, 208000000X, 2080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903650Medicaid
IN000000774382OtherANTHEM PTAN
IN000000769478OtherANTHEM PTAN
INP01339696OtherRAILROAD MEDICARE