Basic Information
| Provider Information | |||||||||
| NPI: | 1154340461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKESLEE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224110 | ||||||||
| FaxNumber: | 5707683911 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 HOSPITAL DR STE 212 | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705229771 | ||||||||
| FaxNumber: | 5705229772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084S0012X | OS007656L | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084N0400X | OS007656L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P00170649 | 01 | PA | RAILROAD MEDICARE | OTHER | 645269046 | 01 | PA | GEISINGER | OTHER | 50002761 | 01 | PA | KEYSTONE | OTHER | 118438711 | 01 | PA | DEPARTMENT OF LABOR | OTHER | 170622 | 01 | PA | BLUE SHIELD | OTHER | 18423860001 | 05 | PA | MEDICAID | 50002761 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 232809429 | 01 | PA | TRICARE | OTHER | G47849 | 01 | PA | HEALTH AMERICA | OTHER |