Healthcare Provider Details

I. General information

NPI: 1538321047
Provider Name (Legal Business Name): ANNESSA R BLACKMUN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 N BROADWAY ST FLOOR 2
CHICAGO IL
60613-1781
US

IV. Provider business mailing address

PO BOX 23359 FLOOR 2
SAINT LOUIS MO
63156-3359
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-0140
  • Fax: 773-770-0141
Mailing address:
  • Phone: 314-932-1570
  • Fax: 314-932-1571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2010035799
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016.005464
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: