Provider Demographics
NPI:1952416331
Name:SPAIN, BLAKE A (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:A
Last Name:SPAIN
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 1:920 CHURCH ST N
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2927
Mailing Address - Country:US
Mailing Address - Phone:704-403-1331
Mailing Address - Fax:704-403-2533
Practice Address - Street 1:920 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2927
Practice Address - Country:US
Practice Address - Phone:704-403-1331
Practice Address - Fax:704-403-2533
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800704207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053HOtherBCBS ALL PLANS
9840261OtherCIGNA HEALTHCARE
NC791053HMedicaid
1281816OtherUNITED HEALTHCARE
200322OtherMEDCOST
NCNCF236C904Medicare PIN
2260042GMedicare PIN
1281816OtherUNITED HEALTHCARE