Basic Information
Provider Information | |||||||||
NPI: | 1588750509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACKFORD | ||||||||
FirstName: | TERRANCE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 HOSPITAL BLVD | ||||||||
Address2: |   | ||||||||
City: | JEFFERSONVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 471303769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122823899 | ||||||||
FaxNumber: | 8122824172 | ||||||||
Practice Location | |||||||||
Address1: | 1900 BLUEGRASS AVE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 40215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5023750009 | ||||||||
FaxNumber: | 5023752150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 04/20/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 37196 | KY | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 65909285 | 05 | KY |   | MEDICAID | 7616735001 | 01 |   | CIGNA | OTHER | 340020112 | 01 |   | RAILROAD MEDICARE | OTHER | 340020112 | 01 | KY | RAILROAD MEDICARE | OTHER | 7771374 | 01 |   | AETNA | OTHER | 1168051 | 01 | KY | PASSPORT | OTHER | 000000231288 | 01 |   | ANTHEM | OTHER | 1106100 | 01 | KY | PASSPORT | OTHER | 64055122 | 05 | KY |   | MEDICAID |