Provider Demographics
NPI:1588640510
Name:BLACKMAN, ANN E (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:E
Last Name:BLACKMAN
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 1:608 OLD ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-3730
Mailing Address - Country:US
Mailing Address - Phone:573-336-5100
Mailing Address - Fax:
Practice Address - Street 1:608 OLD ROUTE 66
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3730
Practice Address - Country:US
Practice Address - Phone:573-336-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34727207Q00000X
MO2010007130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00837677OtherRAILROAD MEDICARE
IAPO00168051OtherRR MEDICARE
MO1588640510Medicaid
IA1242164Medicaid
MO135570022OtherMEDICARE PTAN
MO135570022OtherMEDICARE PTAN
MOP00837677OtherRAILROAD MEDICARE