1609836824 NPI number — DR. GRIFFITH BLACKMON MD

Table of content: DR. GRIFFITH BLACKMON MD (NPI 1609836824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609836824 NPI number — DR. GRIFFITH BLACKMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKMON
Provider First Name:
GRIFFITH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609836824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2520 CHERRY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98310-4229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-744-5804
Provider Business Mailing Address Fax Number:
206-965-4279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2520 CHERRY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310-4229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-744-5804
Provider Business Practice Location Address Fax Number:
206-965-4279
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  MD00029049 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LC0200X , with the licence number: MD00029049 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: MD00029049 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: MD00029049 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1014390 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1115468 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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