Individual
ETHAN WADE BLACKBURN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
315 E BROADWAY STE 195, LOUISVILLE, KY 40202-3700
(502) 629-4263
(502) 629-4282
Mailing address
PO BOX 776351, CHICAGO, IL 60677-6351
(502) 588-9490
(502) 272-5116
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
01071401B
IN
207X00000X
Orthopaedic Surgery Physician
45826
KY
207XS0106X
Orthopaedic Hand Surgery Physician
Primary
45826
KY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000833108
ANTHEM - LAH
KY
01
—
149325
SIHO
KY
01
—
50052189
PASSPORT
KY
05
—
7100250140
—
KY
Enumeration date
04/24/2007
Last updated
01/12/2021
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