Provider Demographics
NPI:1245529825
Name:BLAKE, LAUREN BEEZLEY (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:BEEZLEY
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-5110
Practice Address - Fax:573-335-4689
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018008132207P00000X
LAMD.207045207P00000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2149741Medicaid
LA358106YJA2Medicare PIN