Provider Demographics
NPI:1841511037
Name:BLACKBURN, JOHN W (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
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:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-430-3500
Mailing Address - Fax:606-437-1033
Practice Address - Street 1:911 BYPASS RD BLDG A
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1689
Practice Address - Country:US
Practice Address - Phone:606-430-3500
Practice Address - Fax:606-437-1033
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4204207L00000X
GA072985207LC0200X
OK31227207LP2900X
KY48968207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100406930Medicaid
KY7100406930Medicaid