Healthcare Provider Details

I. General information

NPI: 1316907629
Provider Name (Legal Business Name): ROY M BLACKBURN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 RIVER ROAD SUITE 101
EUGENE OR
97404
US

IV. Provider business mailing address

PO BOX 849095
DALLAS TX
75284-9095
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-8469
  • Fax: 541-687-8631
Mailing address:
  • Phone: 541-344-8469
  • Fax: 541-687-8631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD22132
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: