Basic Information
| Provider Information | |||||||||
| NPI: | 1265411896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 347 | ||||||||
| Address2: | |||||||||
| City: | BLACKLICK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430040347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145520061 | ||||||||
| FaxNumber: | 6145520168 | ||||||||
| Practice Location | |||||||||
| Address1: | 6001 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432131502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145520061 | ||||||||
| FaxNumber: | 6145520168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 35-053889 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | 35.053889 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2016437 | 05 | OH | MEDICAID | 10826581 | 01 | OH | CAQH | OTHER |