Basic Information
| Provider Information | |||||||||
| NPI: | 1770627234 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLAKE WELLING, MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4403 HARRISON BLVD | ||||||||
| Address2: | SUITE 1815 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013876520 | ||||||||
| FaxNumber: | 8013876525 | ||||||||
| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD | ||||||||
| Address2: | SUITE 1815 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013876520 | ||||||||
| FaxNumber: | 8013876525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2007 | ||||||||
| LastUpdateDate: | 02/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | WELLING | ||||||||
| AuthorizedOfficialFirstName: | BLAKE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8013876520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 97-344917-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 528113182005 | 05 | UT | MEDICAID |