Basic Information
| Provider Information | |||||||||
| NPI: | 1558329177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472752 | ||||||||
| FaxNumber: | 4134966836 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 TOR COURT | ||||||||
| Address2: | HILLCREST FAMILY HEALTH | ||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134992054 | ||||||||
| FaxNumber: | 4134459517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 208404 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0137251 | 05 | MA | MEDICAID |