Provider Demographics
NPI:1043470990
Name:BLACKHAM, RICHARD BRENNAN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRENNAN
Last Name:BLACKHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5171 S COTTONWOOD ST
Mailing Address - Street 2:SUITE, 810
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5704
Mailing Address - Country:US
Mailing Address - Phone:801-505-9800
Mailing Address - Fax:801-507-9801
Practice Address - Street 1:5171 S COTTONWOOD ST
Practice Address - Street 2:SUITE, 810
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5704
Practice Address - Country:US
Practice Address - Phone:801-507-9800
Practice Address - Fax:801-507-9801
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ461082081P2900X
UT8627317-12052081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine