MEDICARE: JACQUES D BLACKMAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	17181	KS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	021348	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023040334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUES D BLACKMAN MD

Provider Business Mailing Address
First Line	:	PO BOX 8035
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67208-0035
Country	:	US
Telephone Number	:	316-689-9135
Fax Number	:	316-689-9102

Provider Business Practice Location Address
First Line	:	13213 W 21ST ST N
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67235-9625
Country	:	US
Telephone Number	:	316-945-0142
Fax Number	:	316-946-1760

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	03/24/2015

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