Provider Demographics
NPI:1033102124
Name:BLACKBURN, BRADLEY A (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
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 638269
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-4455
Mailing Address - Country:US
Mailing Address - Phone:440-816-4250
Mailing Address - Fax:
Practice Address - Street 1:18181 PEARL RD STE A102
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-6951
Practice Address - Country:US
Practice Address - Phone:440-816-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350534372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0304914OtherBCMH
OH4007005OtherAETNA
OH414948OtherWELLCARE
OH740475OtherBUCKEYE
OH000000221054OtherUNISON
OH000000511513OtherANTHEM
OH000000302578OtherANTHEM
OH0629172Medicaid
OHP00412281OtherRAILROAD MEDICARE
OHP00412281OtherRAILROAD MEDICARE
OH000000221054OtherUNISON
OH000000511513OtherANTHEM
OHBL4149964Medicare PIN