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NPI Code Detail

MEDICARE: DR. RICHARD JAY BLACKBURN DO

MEDICARE: DR. RICHARD JAY BLACKBURN DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician1455WV

General Provider Information

NPI Number : 1275519878
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. RICHARD JAY BLACKBURN DO
Provider Business Mailing Address
First Line : 705 WASHINGTON ST
Second Line :
City : RAVENSWOOD
State : WV
Zip : 26164-1729
Country : US
Telephone Number : 304-868-6000
Fax Number : 304-868-6002
Provider Business Practice Location Address
First Line : 705 WASHINGTON ST
Second Line :
City : RAVENSWOOD
State : WV
Zip : 26164-1729
Country : US
Telephone Number : 304-868-6000
Fax Number : 304-868-6002
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/16/2005
Last Update Date : 07/08/2007

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