Provider Demographics
NPI:1477597326
Name:BLACKBURN, GERALD W (DO)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:W
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28080 GRAND RIVER AVE STE 306
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:947-521-8314
Practice Address - Fax:248-478-8864
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101006566207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI128362OtherCARE CHOICES
MIC2545OtherMCARE
MIP49607OtherBLUE CROSS
MI4385108OtherAETNA
MI5630027OtherBLUE CROSS
MIOF37018001Medicare ID - Type Unspecified