Basic Information
| Provider Information | |||||||||
| NPI: | 1891741567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | LEE ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 DRAWER 1492 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352461492 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 7TH AVE S | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059399810 | ||||||||
| FaxNumber: | 2059399949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD.21391 | AL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | MD.21391 | AL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 115836 | 05 | AL | MEDICAID | 39780 | 01 | AL | BCBS | OTHER | 511-03877 | 01 | AL | FEDERAL BC | OTHER | 051039780 | 05 | AL | MEDICAID | 511-02194 | 01 | AL | BCBS | OTHER | 1891741567 | 01 | AL | TRICARE SOUTH | OTHER | 98345 | 01 | AL | BCBS | OTHER | 115827 | 05 | AL | MEDICAID | 511-03879 | 01 | AL | FEDERAL BC | OTHER | 511-02189 | 01 | AL | BCBS | OTHER |