Provider Demographics
NPI:1063429652
Name:BLACKBURN, MICHAEL GREGORY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GREGORY
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:G
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, INC, PS
Mailing Address - Street 1:201 15TH AVE SW STE C
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7495
Mailing Address - Country:US
Mailing Address - Phone:253-841-4243
Mailing Address - Fax:253-864-9452
Practice Address - Street 1:201 15TH AVE SW STE C
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7495
Practice Address - Country:US
Practice Address - Phone:253-841-4243
Practice Address - Fax:253-864-9452
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019306207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1008895Medicaid
WABL4674OtherREGENCE
110008458OtherRAILROAD MEDICARE
110008458OtherRAILROAD MEDICARE
WA1008895Medicaid