Provider Demographics
NPI:1750351037
Name:BLACKBURN, GLENN KOONTZ JR (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:KOONTZ
Last Name:BLACKBURN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:CHILDREN'S CLINIC
Mailing Address - Street 2:350 LANGDON ST.
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-678-8155
Mailing Address - Fax:606-678-7548
Practice Address - Street 1:CHILDREN'S CLINIC
Practice Address - Street 2:350 LANGDON ST.
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-678-8155
Practice Address - Fax:606-678-7548
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY162072080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64162076Medicaid
KY64162076Medicaid