MEDICARE: KIM BLACKWELL LPT

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	225100000X	Physical Therapist	03654

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	:	1851428130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM BLACKWELL LPT

Provider Business Mailing Address
First Line	:	2401 TOWNCREST DR
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52240-6631
Country	:	US
Telephone Number	:	319-354-2429
Fax Number	:	319-354-6100

Provider Business Practice Location Address
First Line	:	1101 5TH ST
Second Line	:	SUITE 100
City	:	CORALVILLE
State	:	IA
Zip	:	52241-2903
Country	:	US
Telephone Number	:	319-341-3442
Fax Number	:	319-341-0836

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/08/2007

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Directions to “ KIM BLACKWELL LPT” Practice Location

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