Healthcare Provider Details

I. General information

NPI: 1336435056
Provider Name (Legal Business Name): BRIAN P BLACKWOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST 527 ACFAC
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

111 E CHESTNUT ST APT 32G
CHICAGO IL
60611-2018
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6510
  • Fax:
Mailing address:
  • Phone: 225-247-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125060193
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: