Provider Demographics
NPI:1700318987
Name:BLAKE, SCOTT PATRICK
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:PATRICK
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 MORSE LANDING DR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IN
Mailing Address - Zip Code:46034-9519
Mailing Address - Country:US
Mailing Address - Phone:317-379-3893
Mailing Address - Fax:
Practice Address - Street 1:1711 N 6TH 1/2 ST STE 100
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2700
Practice Address - Country:US
Practice Address - Phone:859-257-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program