Individual
DR. GLENN KOONTZ BLACKBURN JR.
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
CHILDREN'S CLINIC, 350 LANGDON ST., SOMERSET, KY 42503
(606) 678-8155
(606) 678-7548
Mailing address
CHILDREN'S CLINIC, 350 LANGDON ST., SOMERSET, KY 42503
(606) 678-8155
(606) 678-7548
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
16207
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
64162076
—
KY
Enumeration date
01/26/2006
Last updated
07/09/2007
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