Healthcare Provider Details

I. General information

NPI: 1043470990
Provider Name (Legal Business Name): RICHARD BRENNAN BLACKHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 S COTTONWOOD ST SUITE, 810
MURRAY UT
84107-5704
US

IV. Provider business mailing address

5171 S COTTONWOOD ST SUITE, 810
MURRAY UT
84107-5704
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-9800
  • Fax: 801-507-9801
Mailing address:
  • Phone: 801-505-9800
  • Fax: 801-507-9801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number46108
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number8627317-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: