Provider Demographics
NPI:1538387360
Name:BLACKBURN, ETHAN WADE (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:WADE
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:315 E BROADWAY STE 195
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-629-4263
Practice Address - Fax:502-629-4282
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45826207X00000X, 207XS0106X
IN01071401B207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100250140Medicaid
KY000000833108OtherANTHEM - LAH
KY149325OtherSIHO
KY50052189OtherPASSPORT
KY50052189OtherPASSPORT
KY000000833108OtherANTHEM - LAH