1285801480 NPI number — MICHAEL G. BLACKBURN, M.D. , INC. P.S.

Table of content: (NPI 1285801480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285801480 NPI number — MICHAEL G. BLACKBURN, M.D. , INC. P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL G. BLACKBURN, M.D. , INC. P.S.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1285801480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 15TH AVE SW STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-7495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-841-4243
Provider Business Mailing Address Fax Number:
253-864-9452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 15TH AVE SW STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98371-7495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-4243
Provider Business Practice Location Address Fax Number:
253-864-9452
Provider Enumeration Date:
05/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLACKBURN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
253-841-4243

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD00019306 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1008895 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: BL4674 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 110008458 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".