Healthcare Provider Details

I. General information

NPI: 1124025101
Provider Name (Legal Business Name): WILLIAM E BLACKBURN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 NICHOLASVILLE RD SUITE 301
LEXINGTON KY
40503-1471
US

IV. Provider business mailing address

1760 NICHOLASVILLE RD SUITE 301
LEXINGTON KY
40503-1471
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-5766
  • Fax: 859-277-3406
Mailing address:
  • Phone: 859-277-5766
  • Fax: 859-277-3406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number15471
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: