Provider Demographics
NPI:1730183138
Name:BLACKBURN, JOSEPH BRUCE (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BRUCE
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 1:1075 S COURT ST
Mailing Address - Street 2:STE 100
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3836
Mailing Address - Country:US
Mailing Address - Phone:330-722-6337
Mailing Address - Fax:330-722-0481
Practice Address - Street 1:1075 S COURT ST
Practice Address - Street 2:STE 100
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3836
Practice Address - Country:US
Practice Address - Phone:330-722-6337
Practice Address - Fax:330-722-0481
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2010-01-07
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
OH350-77002-B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2152281Medicaid
OH2152281Medicaid
H07725Medicare UPIN