Healthcare Provider Details

I. General information

NPI: 1417176249
Provider Name (Legal Business Name): TRISTAN DEE BLACKBURN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 DUTCHMANS LN STE 208
LOUISVILLE KY
40207-4723
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-6061
  • Fax: 502-899-6127
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number46118
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: