Provider Demographics
NPI:1366917163
Name:BLAKE MEDICAL LLC
Entity type:Organization
Organization Name:BLAKE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-541-1864
Mailing Address - Street 1:36 CENTRE LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-3912
Mailing Address - Country:US
Mailing Address - Phone:718-541-1864
Mailing Address - Fax:458-201-6005
Practice Address - Street 1:3 WOODLAND RD STE 318
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1713
Practice Address - Country:US
Practice Address - Phone:617-939-1602
Practice Address - Fax:458-201-6005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1100850080AMedicaid