Basic Information
| Provider Information | |||||||||
| NPI: | 1578513701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 HIGHLAND BLVD | ||||||||
| Address2: | ATTN PFS CREDENTIALING | ||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 937 HIGHLAND BLVD STE 5320 | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064144900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 12120 | MT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 209287408 | 05 | MO | MEDICAID | 1578513701 | 05 | MT | MEDICAID |