Provider Demographics
NPI:1447912472
Name:BLACKMAN, MICHAEL NOBLES
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NOBLES
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:NOBLE
Other - Last Name:BLACKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 W TIOGA ST # 201
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4936
Mailing Address - Country:US
Mailing Address - Phone:223-400-9882
Mailing Address - Fax:
Practice Address - Street 1:1700 W TIOGA ST # 201
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4936
Practice Address - Country:US
Practice Address - Phone:223-400-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA24015689251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health