1588640510 NPI number — ANN E BLACKMAN MD

Table of content: ANN E BLACKMAN MD (NPI 1588640510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588640510 NPI number — ANN E BLACKMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKMAN
Provider First Name:
ANN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588640510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
608 OLD ROUTE 66
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT ROBERT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65584-3730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-336-5100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
608 OLD ROUTE 66
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ROBERT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65584-3730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-336-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34727 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2010007130 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00837677 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: PO00168051 . This is a "RR MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1588640510 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1242164 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135570022 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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