Provider Demographics
NPI:1548305097
Name:THOMAS R. BLACKBURN, MD, PA
Entity type:Organization
Organization Name:THOMAS R. BLACKBURN, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:REID
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-482-0386
Mailing Address - Street 1:1327 KINGS CIR
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-6030
Mailing Address - Country:US
Mailing Address - Phone:704-482-0386
Mailing Address - Fax:
Practice Address - Street 1:201 E PARKER RD
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-5107
Practice Address - Country:US
Practice Address - Phone:828-433-1206
Practice Address - Fax:828-433-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14614261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14614OtherNC LICENSE NO.
NCC87385Medicare UPIN