Provider Demographics
NPI:1588750509
Name:BLACKFORD, TERRANCE L (MD)
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:L
Last Name:BLACKFORD
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 1:101 HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3769
Mailing Address - Country:US
Mailing Address - Phone:812-282-3899
Mailing Address - Fax:812-282-4172
Practice Address - Street 1:1900 BLUEGRASS AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-375-0009
Practice Address - Fax:502-375-2150
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37196208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65909285Medicaid
7616735001OtherCIGNA
340020112OtherRAILROAD MEDICARE
KY340020112OtherRAILROAD MEDICARE
7771374OtherAETNA
KY1168051OtherPASSPORT
000000231288OtherANTHEM
KY1106100OtherPASSPORT
KY64055122Medicaid
0615304Medicare ID - Type Unspecified
340020112OtherRAILROAD MEDICARE
7771374OtherAETNA