1538321047 NPI number — ANNESSA R BLACKMUN DPM

Table of content: ANNESSA R BLACKMUN DPM (NPI 1538321047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538321047 NPI number — ANNESSA R BLACKMUN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKMUN
Provider First Name:
ANNESSA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1538321047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23359
Provider Second Line Business Mailing Address:
FLOOR 2
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63156-3359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-932-1570
Provider Business Mailing Address Fax Number:
314-932-1571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4350 N BROADWAY ST
Provider Second Line Business Practice Location Address:
FLOOR 2
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613-1781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-770-0140
Provider Business Practice Location Address Fax Number:
773-770-0141
Provider Enumeration Date:
06/26/2008

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: 213ES0103X , with the licence number:  2010035799 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 016.005464 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P01781390 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1538321047 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01796928 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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