Basic Information
| Provider Information | |||||||||
| NPI: | 1063409639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKELEY | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086525250 | ||||||||
| FaxNumber: | 2086255251 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 N THIRD AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082638505 | ||||||||
| FaxNumber: | 2082632908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 16299 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 3859386 | 05 | TN | MEDICAID |