Provider Demographics
NPI:1295959310
Name:BLAKE FAMILY MEDICINE PLLC
Entity type:Organization
Organization Name:BLAKE FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:910-754-4545
Mailing Address - Street 1:PO BOX 3206
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-3206
Mailing Address - Country:US
Mailing Address - Phone:910-754-4545
Mailing Address - Fax:910-754-4794
Practice Address - Street 1:4704 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-1880
Practice Address - Country:US
Practice Address - Phone:910-754-4545
Practice Address - Fax:910-754-4794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10868207Q00000X
NC103290363A00000X
NC103296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902868Medicaid
NC017W4OtherBCBS GRP
NC55210OtherBCBS
NC185616OtherMEDCOST
NC858799OtherUHC
NC5902868Medicaid
NC201990NMedicare ID - Type Unspecified
NCC81005Medicare UPIN
NC2757351AMedicare ID - Type Unspecified
NC55210OtherBCBS
NC2761835Medicare ID - Type Unspecified
NC2340782Medicare ID - Type UnspecifiedMEDICARE GRP