Provider Demographics
NPI:1699702308
Name:BLAKE, RICHARD ALAN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7840
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE A-300
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-276-4429
Practice Address - Fax:859-276-5939
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29029207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KYCB5773OtherRR MEDICARE GROUP
KY64290299Medicaid
KY36000818OtherMEDICAID ASC GROUP
KYASC1019OtherMEDICARE ASC GROUP
KY06003363OtherRR MEDICARE PIN
KY37903705OtherMEDICAID LAB GROUP
KY36000818OtherMEDICAID ASC GROUP
KY06003363OtherRR MEDICARE PIN