Basic Information
| Provider Information | |||||||||
| NPI: | 1639466873 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BUSEY | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | RON | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 ANDREWS RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283111156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098636070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2817 REILLY ROAD MCXC-COD CREDENTIALS | ||||||||
| Address2: | WOMACK ARMY MEDICAL CENTER | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078007 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2011 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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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 | 207Q00000X | R6530 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.