Provider Demographics
NPI:1922192947
Name:BLAKELY, MARK H (DPT,OCS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:H
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:DPT,OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MARKET ST STE 4103
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-5636
Mailing Address - Country:US
Mailing Address - Phone:828-342-7358
Mailing Address - Fax:
Practice Address - Street 1:4 MARKET ST
Practice Address - Street 2:SUITE 4103
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-5635
Practice Address - Country:US
Practice Address - Phone:828-877-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NCNC7217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC650016318OtherRR MEDICARE #
NC7211278Medicaid
NCB8364OtherMEDCOST #
NC078RCOtherBLUE CROSS BLUE SHIELD #
NC2502490Medicare ID - Type Unspecified