Provider Demographics
NPI:1003896119
Name:BLACKMORE, MICHAEL ADAMS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ADAMS
Last Name:BLACKMORE
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 1:20 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-3232
Mailing Address - Country:US
Mailing Address - Phone:641-422-9000
Mailing Address - Fax:641-422-9088
Practice Address - Street 1:20 5TH ST NW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-3232
Practice Address - Country:US
Practice Address - Phone:641-422-9000
Practice Address - Fax:641-422-9088
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA270732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA8106872Medicaid
IAF16965Medicare UPIN
IA59225Medicare ID - Type Unspecified