Provider Demographics
NPI:1487695219
Name:BLACKHAM, KRISTINE A (MD)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:BLACKHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1736
Practice Address - Country:US
Practice Address - Phone:216-844-1700
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350841812085N0700X, 2085B0100X, 2085D0003X, 2085R0202X, 2085U0001X, 2085H0002X, 2085N0904X, 2085P0229X, 2085R0001X, 2085R0203X, 2085R0204X, 207U00000X, 207UN0903X, 207UN0901X, 207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085H0002XAllopathic & Osteopathic PhysiciansRadiologyHospice and Palliative Medicine
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0903XAllopathic & Osteopathic PhysiciansNuclear MedicineIn Vivo & In Vitro Nuclear Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023171400001Medicaid
OH732926OtherBUCKEYE
OH2493707Medicaid
OH000000503569OtherANTHEM
OH0304914OtherBCMH
OH751556OtherAETNA
OHP00358779OtherRAILROAD MEDICARE
OH000000206509OtherUNISON
MI1487695219OtherMI MEDICAID
OH363360OtherWELLCARE
OH0304914OtherBCMH
MI1487695219OtherMI MEDICAID
OHBL4142693Medicare PIN