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General NPI Number Information
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NPI Number | 1285801480
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Entity Type | Organization
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Legal Business Name | MICHAEL G. BLACKBURN, M.D. , INC. P.S.
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Dates
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Enumeration Date | 05/15/2008
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Last Update Date | 07/23/2019
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Provider Practice Location Address
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Address Line | 201 15TH AVE SW STE C
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City | PUYALLUP
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State | WA
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Zip | 98371-7495
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Country | US
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Telephone | 253-841-4243
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Fax | 253-864-9452
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Provider Business Mailing Address
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Address Line | 201 15TH AVE SW STE C
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City | PUYALLUP
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State | WA
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Zip | 98371-7495
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Country | US
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Telephone | 253-841-4243
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Fax | 253-864-9452
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL G. BLACKBURN
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Credential | M.D.
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Telephone | 253-841-4243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MD00019306
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License Number State | WA
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