Provider Demographics
NPI:1154521466
Name:BLAKE SURGICAL ASSOCIATION PLLC
Entity type:Organization
Organization Name:BLAKE SURGICAL ASSOCIATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-846-8880
Mailing Address - Street 1:907 E SUNFLOWER RD
Mailing Address - Street 2:101
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2830
Mailing Address - Country:US
Mailing Address - Phone:662-846-8880
Mailing Address - Fax:662-846-8886
Practice Address - Street 1:907 E SUNFLOWER RD #101
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2833
Practice Address - Country:US
Practice Address - Phone:662-846-8880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16881208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS020000545OtherMEDICARE PROVIDER #
MSC03406OtherMEDICARE GROUP #
MS00122620Medicaid
MSC03406OtherMEDICARE GROUP #