Basic Information
| Provider Information | |||||||||
| NPI: | 1588640510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKMAN | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 608 OLD ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | SAINT ROBERT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655843730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733365100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 608 OLD ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | SAINT ROBERT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655843730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733365100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34727 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2010007130 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00837677 | 01 | MO | RAILROAD MEDICARE | OTHER | PO00168051 | 01 | IA | RR MEDICARE | OTHER | 1588640510 | 05 | MO | MEDICAID | 1242164 | 05 | IA | MEDICAID | 135570022 | 01 | MO | MEDICARE PTAN | OTHER |