Provider Demographics
NPI:1558325605
Name:BLACKBURN, TIMOTHY L (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:BLACKBURN
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 1:2316 E MEYER BLVD STE 509
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64132-1136
Mailing Address - Country:US
Mailing Address - Phone:816-276-4800
Mailing Address - Fax:816-523-1425
Practice Address - Street 1:17067 S OUTER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2165
Practice Address - Country:US
Practice Address - Phone:816-348-4281
Practice Address - Fax:816-348-4271
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2P33207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO060066709OtherRAILROAD MEDICARE
MO1558325605Medicaid
MO17891028OtherBCBS-KC
MOF13087Medicare UPIN
MOMA2231014Medicare PIN
MO17891028OtherBCBS-KC