Basic Information
| Provider Information | |||||||||
| NPI: | 1215099833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMAN | ||||||||
| FirstName: | GURVAN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 QUAKERBRIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096891600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2501 KUSER RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095858800 | ||||||||
| FaxNumber: | 6095851825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD439456 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA08730800 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | MD439456 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 25MA08730800 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 102448287 | 05 | PA | MEDICAID | 0227579 | 05 | NJ | MEDICAID |