NPIMap

Kenneth Todd Blackner, M.D.

Individual provider Active NPI General Practice Physician · Shelley, ID

NPI 1043339641 · NPPES record last updated Feb 3, 2016

Key facts

NPI
1043339641
Entity type
Individual (NPI type 1)
Primary specialty
General Practice Physician 208D00000X
License
M-11785 (ID)
Practice address
275 W Locust St
Shelley, ID 83274-1230
Phone
(208) 357-3960
NPI assigned
Mar 28, 2007
Sex
Male
Sole proprietor
Yes

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

  • BMH Inc Critical Access Hospital · Blackfoot, ID · NPI 1982805271
    NPD

Medicare participation

Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)
Yes
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
M-11785IDMDGeneral Practice Physician
0101240258VAMDGeneral Practice Physician

Practice roles

OrganizationSpecialtyStatusNew patients
BMH Inc Current Accepting new patients

Locations

98 Poplar St
Blackfoot, ID 83221
Phone (208) 782-3763

Interoperability endpoints

  • Direct secure messaging: kennethblackner@bmh.medalliesdirect.net

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Physician 208D00000X 0101240258 VA
General Practice Physician 208D00000X M-11785 ID Yes

Addresses

Primary practice location

275 W Locust St
Shelley, ID 83274-1230

Mailing address

618 E 1450 N
Shelley, ID 83274-5078
Phone (757) 617-3339

Other providers in Shelley, ID

All providers in Shelley, ID · General Practice Physician in Idaho

Sources for this page

Verify at the official NPI Registry.