Provider Demographics
NPI:1063409639
Name:BLAKELEY, RUSSELL R (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:R
Last Name:BLAKELEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-652-5250
Mailing Address - Fax:208-625-5251
Practice Address - Street 1:606 N THIRD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1594
Practice Address - Country:US
Practice Address - Phone:208-263-8505
Practice Address - Fax:208-263-2908
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN16299207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3859386Medicaid
TND93197Medicare UPIN
TN103I060787Medicare PIN
TN3859385Medicare PIN
TN103I066492Medicare PIN
P00841514Medicare PIN
60068974Medicare PIN