Provider Demographics
NPI:1326146754
Name:GREGARY M. BLACKNER INC. P.S.
Entity Type:Organization
Organization Name:GREGARY M. BLACKNER INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-786-1297
Mailing Address - Street 1:403 BLACK HILLS LN SW
Mailing Address - Street 2:STE B
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8600
Mailing Address - Country:US
Mailing Address - Phone:360-786-1297
Mailing Address - Fax:360-534-9043
Practice Address - Street 1:403 BLACK HILLS LN SW
Practice Address - Street 2:B
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8600
Practice Address - Country:US
Practice Address - Phone:360-786-1297
Practice Address - Fax:360-534-9043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA26210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========Medicare UPIN