Basic Information
| Provider Information | |||||||||
| NPI: | 1538185384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE-GUMBS | ||||||||
| FirstName: | LYLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168443944 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
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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 | 207Q00000X | 35-084366 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000224354 | 01 | UNISON | OTHER | 363362 | 01 | WELLCARE | OTHER | P00333095 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000382819 | 01 | OH | ANTHEM | OTHER | 2472793 | 05 | OH | MEDICAID | 000000530381 | 01 | OH | ANTHEM | OTHER | 7082178 | 01 | OH | AETNA | OTHER | 737670 | 01 | OH | BUCKEYE | OTHER |