Basic Information
| Provider Information | |||||||||
| NPI: | 1588855803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 HOSPITAL PL | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996696999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 250 HOSPITAL PLACE | ||||||||
| Address2: | CENTRAL PENINSULA HOSPITAL | ||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302088388 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204R00000X | 20A11305 | CA | N | Allopathic & Osteopathic Physicians | Electrodiagnostic Medicine | 207P00000X | DO1534 | NV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 7612 | AK | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.