Basic Information
| Provider Information | |||||||||
| NPI: | 1750351037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | KOONTZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | CHILDREN'S CLINIC | ||||||||
| Address2: | 350 LANGDON ST. | ||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066788155 | ||||||||
| FaxNumber: | 6066787548 | ||||||||
| Practice Location | |||||||||
| Address1: | CHILDREN'S CLINIC | ||||||||
| Address2: | 350 LANGDON ST. | ||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066788155 | ||||||||
| FaxNumber: | 6066787548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 2080A0000X | 16207 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64162076 | 05 | KY | MEDICAID |