Provider Demographics
NPI:1215148077
Name:BLACKBURN, STACI CHRISTINE (MD)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:CHRISTINE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACE
Other - Middle Name:
Other - Last Name:VALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:3RD FLOOR TAUBMAN CTR RECP 'B'
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5352
Practice Address - Country:US
Practice Address - Phone:734-936-5582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084180208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist