Provider Demographics
NPI:1265595524
Name:BLACKBURN, MAGGIE (MAGGIE BLACKBURN MD)
Entity type:Individual
Prefix:DR
First Name:MAGGIE
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MAGGIE BLACKBURN MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 REMINGTON RUN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-1473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3410 REMINGTON RUN
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-1473
Practice Address - Country:US
Practice Address - Phone:850-644-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190386207Q00000X
FLME99422208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01498484Medicaid
NY05K601Medicare ID - Type Unspecified
NYF5K602Medicare UPIN