Provider Demographics
NPI:1538321047
Name:BLACKMUN, ANNESSA R (DPM)
Entity Type:Individual
Prefix:
First Name:ANNESSA
Middle Name:R
Last Name:BLACKMUN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23359
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3359
Mailing Address - Country:US
Mailing Address - Phone:314-932-1570
Mailing Address - Fax:314-932-1571
Practice Address - Street 1:4350 N BROADWAY ST
Practice Address - Street 2:FLOOR 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1781
Practice Address - Country:US
Practice Address - Phone:773-770-0140
Practice Address - Fax:773-770-0141
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010035799213ES0103X
IL016.005464213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01781390OtherRAILROAD MEDICARE
MO1538321047Medicaid
ILP01796928OtherRAILROAD MEDICARE
MO1538321047Medicaid
MOP01781390OtherRAILROAD MEDICARE
MO149630014Medicare PIN
ILP01796928OtherRAILROAD MEDICARE