Healthcare Provider Details

I. General information

NPI: 1437412582
Provider Name (Legal Business Name): ANDREW T BLACKBURNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 PIPER HILL DR STE 12
SAINT PETERS MO
63376-1690
US

IV. Provider business mailing address

12855 N 40 DR STE 375
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 636-996-9202
  • Fax: 314-743-1338
Mailing address:
  • Phone: 314-567-6071
  • Fax: 314-567-3321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2017014167
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036156280
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: