Provider Demographics
NPI:1063545788
Name:BLAKEMORE, ALFRED
Entity type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:
Last Name:BLAKEMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 BOTANICAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-4002
Mailing Address - Country:US
Mailing Address - Phone:341-664-8616
Mailing Address - Fax:
Practice Address - Street 1:3642 BOTANICAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-4002
Practice Address - Country:US
Practice Address - Phone:341-664-8616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7147Medicaid