MEDICARE: GREGARY M BLACKNER M.D.

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	MD00026210	WA

Other Identifiers

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

General Provider Information

NPI Number	:	1316050602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGARY M BLACKNER M.D.

Provider Business Mailing Address
First Line	:	PO BOX 721
Second Line	:
City	:	KAYSVILLE
State	:	UT
Zip	:	84037-0721
Country	:	US
Telephone Number	:	801-682-8190
Fax Number	:	801-214-1875

Provider Business Practice Location Address
First Line	:	1617 SUMMIT LAKE SHORE RD NW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-9437
Country	:	US
Telephone Number	:	801-682-8190
Fax Number	:	801-214-1875

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	05/25/2021

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