Provider Demographics
NPI:1285801480
Name:MICHAEL G. BLACKBURN, M.D. , INC. P.S.
Entity type:Organization
Organization Name:MICHAEL G. BLACKBURN, M.D. , INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-841-4243
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019306261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1008895Medicaid
WABL4674OtherREGENCE
110008458OtherRAILROAD MEDICARE
110008458OtherRAILROAD MEDICARE
WAA08326Medicare UPIN