Provider Demographics
NPI:1508813361
Name:BLAKELY, BRENT M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:M
Last Name:BLAKELY
Suffix:
Gender:M
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:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72145-0144
Mailing Address - Country:US
Mailing Address - Phone:501-279-2426
Mailing Address - Fax:501-279-2501
Practice Address - Street 1:3214 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4810
Practice Address - Country:US
Practice Address - Phone:501-268-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8352207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR050038809OtherRR MEDICARE GRP# CD7786
AR5J775OtherBLUE CROSS BLUE SHIELD
AR127486001Medicaid
AR050038809OtherRR MEDICARE GRP# CD7786
AR127486001Medicaid