Provider Demographics
NPI:1265602478
Name:BLACKBURN, SARA MARIE GENUTIS (MD)
Entity type:Individual
Prefix:DR
First Name:SARA
Middle Name:MARIE GENUTIS
Last Name:BLACKBURN
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 1:8600 NICOLLET AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2824
Mailing Address - Country:US
Mailing Address - Phone:952-541-2800
Mailing Address - Fax:952-886-7023
Practice Address - Street 1:8600 NICOLLET AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-2824
Practice Address - Country:US
Practice Address - Phone:952-541-2800
Practice Address - Fax:952-886-7023
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015934208000000X
MN56809208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1265602478Medicaid
175150022OtherMEDICARE
GA0002495187Medicaid