NPIMap

Organization Active NPI

Blake Family Medicine PLLC

  • Family Medicine Physician
  • Shallotte, NC
National Provider Identifier
1295959310
Registry record updated Sep 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
10868 Issued in NC
Legal business name
BLAKE FAMILY MEDICINE PLLC
Practice address
4704 Main St
Shallotte, NC 28470-1880
Phone
(910) 754-4545
Fax
(910) 754-4794
NPI assigned
Apr 12, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John A Blake, PANPI 1780726570
Title
Owner
Phone
(910) 754-4545

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207Q00000X 10868 NC Primary
Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363A00000X 103290 NC
Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363A00000X 103296 NC

Addresses

Primary practice location

4704 Main St
Shallotte, NC 28470-1880

Mailing address

PO Box 3206
Shallotte, NC 28459-3206
Phone (910) 754-4545

Other identifiers 5

IdentifierTypeStateIssuer
5902868MedicaidNC
017W4OtherNCBCBS GRP
55210OtherNCBCBS
185616OtherNCMEDCOST
858799OtherNCUHC

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176336000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757548800000",
    "number": "1295959310",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3206",
            "city": "SHALLOTTE",
            "state": "NC",
            "postal_code": "284593206",
            "telephone_number": "910-754-4545",
            "fax_number": "910-754-4794"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4704 MAIN ST",
            "city": "SHALLOTTE",
            "state": "NC",
            "postal_code": "284701880",
            "telephone_number": "910-754-4545",
            "fax_number": "910-754-4794"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLAKE FAMILY MEDICINE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-12",
        "last_updated": "2025-09-11",
        "status": "A",
        "authorized_official_last_name": "BLAKE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "910-754-4545",
        "authorized_official_credential": "PA"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "NC",
            "license": "10868",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "103290",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "103296",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5902868",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS GRP",
            "identifier": "017W4",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "55210",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDCOST",
            "identifier": "185616",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UHC",
            "identifier": "858799",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Shallotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.