MEDICARE: BLACKMUN FOOTCARE LLC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	2010035799	MO

General Provider Information

NPI Number	:	1255620340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKMUN FOOTCARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 23359
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63156-3359
Country	:	US
Telephone Number	:	314-932-1570
Fax Number	:

Provider Business Practice Location Address
First Line	:	2608 N 14TH ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63106-3913
Country	:	US
Telephone Number	:	314-932-1570
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANNESSA RENEE' BLACKMUN
Credential	:	DPM
Telephone Number	:	502-418-4809

Provider Enumeration Date	:	03/29/2011
Last Update Date	:	04/05/2016

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