Provider Demographics
NPI:1922014273
Name:BLACKHAM, KERRY ALAN (DO)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ALAN
Last Name:BLACKHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 WEST PINE
Mailing Address - Street 2:
Mailing Address - City:PHILIP
Mailing Address - State:SD
Mailing Address - Zip Code:57567-0550
Mailing Address - Country:US
Mailing Address - Phone:605-859-2566
Mailing Address - Fax:605-859-2948
Practice Address - Street 1:503 W PINE ST
Practice Address - Street 2:
Practice Address - City:PHILIP
Practice Address - State:SD
Practice Address - Zip Code:57567-0550
Practice Address - Country:US
Practice Address - Phone:605-859-2566
Practice Address - Fax:605-859-2948
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9452207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS110986Medicaid