# BLAKE FAMILY MEDICINE PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295959310
- **Authorized official:** JOHN A BLAKE PA (OWNER)
- **Authorized official phone:** (910) 754-4545

## Contact information

- **Practice address:** 4704 MAIN ST, SHALLOTTE, NC 28470-1880
- **Practice address phone:** (910) 754-4545
- **Practice address fax:** (910) 754-4794
- **Mailing address:** PO BOX 3206, SHALLOTTE, NC 28459-3206
- **Mailing address phone:** (910) 754-4545
- **Mailing address fax:** (910) 754-4794

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 10868 | NC | Yes |
| 363A00000X | Physician Assistant | 103290 | NC | — |
| 363A00000X | Physician Assistant | 103296 | NC | — |

## Other

- **Enumeration date:** 04/12/2007
- **Last updated:** 09/11/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 017W4 | BCBS GRP | NC |
| 01 | — | 185616 | MEDCOST | NC |
| 01 | — | 55210 | BCBS | NC |
| 05 | — | 5902868 | — | NC |
| 01 | — | 858799 | UHC | NC |