Healthcare Provider Details

I. General information

NPI: 1255620340
Provider Name (Legal Business Name): BLACKMUN FOOTCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 N 14TH ST
SAINT LOUIS MO
63106-3913
US

IV. Provider business mailing address

PO BOX 23359
SAINT LOUIS MO
63156-3359
US

V. Phone/Fax

Practice location:
  • Phone: 314-932-1570
  • Fax:
Mailing address:
  • Phone: 314-932-1570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2010035799
License Number StateMO

VIII. Authorized Official

Name: DR. ANNESSA RENEE' BLACKMUN
Title or Position: OWNER
Credential: DPM
Phone: 502-418-4809