Provider Demographics
NPI:1720068463
Name:BLACKBURN, VANCE G (MD)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:G
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 VALLEYDALE RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-2019
Mailing Address - Country:US
Mailing Address - Phone:205-980-9944
Mailing Address - Fax:205-980-9844
Practice Address - Street 1:2520 VALLEYDALE RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244-2019
Practice Address - Country:US
Practice Address - Phone:205-980-9944
Practice Address - Fax:205-980-9844
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00013452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC71993Medicare UPIN