Provider Demographics
NPI:1407652159
Name:FERRY, BLAKE WILLIAM
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:WILLIAM
Last Name:FERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3349
Mailing Address - Country:US
Mailing Address - Phone:217-549-8740
Mailing Address - Fax:
Practice Address - Street 1:1170 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7358
Practice Address - Country:US
Practice Address - Phone:618-997-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.031440367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife