Basic Information
| Provider Information | |||||||||
| NPI: | 1760605455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEASE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ERNEST | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086256111 | ||||||||
| FaxNumber: | 2086256112 | ||||||||
| Practice Location | |||||||||
| Address1: | 2177 W IRONWOOD CENTER DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086256111 | ||||||||
| FaxNumber: | 2086256112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | ME108720 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | MED-PHYS-LIC-69984 | MT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | M-16171 | ID | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | HQ038Y | 01 | FL | MEDICARE | OTHER | 010324800 | 05 | FL | MEDICAID | HQ038X | 01 | FL | MEDICARE | OTHER |