Provider Demographics
NPI:1801967047
Name:BLACKBURN, JOEL M (DO)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:M
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:3916 S PROVIDENCE RD STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-7152
Practice Address - Country:US
Practice Address - Phone:573-882-1662
Practice Address - Fax:573-882-4096
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2003004595207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
116134OtherBLUE CROSS/BLUE SHIELD
MO209166909Medicaid