Organization
BLAKE FAMILY MEDICINE PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN A BLAKE PA (OWNER)
(910) 754-4545
Entity
Organization
Contact information
Practice address
4704 MAIN ST, SHALLOTTE, NC 28470-1880
(910) 754-4545
(910) 754-4794
Mailing address
PO BOX 3206, SHALLOTTE, NC 28459-3206
(910) 754-4545
(910) 754-4794
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
10868
NC
363A00000X
Physician Assistant
103290
NC
363A00000X
Physician Assistant
103296
NC
Other
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
Enumeration date
04/12/2007
Last updated
09/11/2025
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