Basic Information
Provider Information | |||||||||
NPI: | 1265602478 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACKBURN | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | MARIE GENUTIS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8600 NICOLLET AVE S | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554202824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525412800 | ||||||||
FaxNumber: | 9528867023 | ||||||||
Practice Location | |||||||||
Address1: | 8600 NICOLLET AVE S | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554202824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525412800 | ||||||||
FaxNumber: | 9528867023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2008 | ||||||||
LastUpdateDate: | 12/23/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2006015934 | MO | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 56809 | MN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1265602478 | 05 | IA |   | MEDICAID | 175150022 | 01 |   | MEDICARE | OTHER | 0002495187 | 05 | GA |   | MEDICAID |