Provider Demographics
NPI:1417176249
Name:BLACKBURN, TRISTAN DEE (MD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:DEE
Last Name:BLACKBURN
Suffix:
Gender:F
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 1:3991 DUTCHMANS LN STE 208
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4723
Practice Address - Country:US
Practice Address - Phone:502-899-6061
Practice Address - Fax:502-899-6127
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46118207RR0500X, 207RR0500X
KYTP018207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100252740Medicaid
IN201069110Medicaid
KY50052639OtherPASSPORT- NORTON RHEUMATOLOGY SPECIALISTS
INP01125709Medicare PIN
KY7100252740Medicaid
IN201069110Medicaid