Basic Information
| Provider Information | |||||||||
| NPI: | 1861424004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 RIVERBEND DR SW | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301616065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062910884 | ||||||||
| FaxNumber: | 7062350405 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 RIVERBEND DR SW | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301616065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062910884 | ||||||||
| FaxNumber: | 7062350405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 055101 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 305104628A | 05 | GA | MEDICAID |