Basic Information
Provider Information | |||||||||
NPI: | 1487695219 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACKHAM | ||||||||
FirstName: | KRISTINE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24701 EUCLID AVE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 441171714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11100 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441061736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168441700 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2006 | ||||||||
LastUpdateDate: | 08/27/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 35084181 | OH | Y |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085B0100X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085D0003X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085R0202X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085H0002X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Hospice and Palliative Medicine | 2085N0904X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0001X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0203X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207U00000X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine |   | 207UN0903X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | In Vivo & In Vitro Nuclear Medicine | 207UN0901X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207UN0902X | 35084181 | OH | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy |
ID Information
ID | Type | State | Issuer | Description | 1023171400001 | 05 | PA |   | MEDICAID | 732926 | 01 | OH | BUCKEYE | OTHER | 2493707 | 05 | OH |   | MEDICAID | 000000503569 | 01 | OH | ANTHEM | OTHER | 0304914 | 01 | OH | BCMH | OTHER | 751556 | 01 | OH | AETNA | OTHER | P00358779 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000206509 | 01 | OH | UNISON | OTHER | 1487695219 | 01 | MI | MI MEDICAID | OTHER | 363360 | 01 | OH | WELLCARE | OTHER |