NPIMap

Individual provider Active NPI

Michael Alan Blackburn, D.O.

  • Family Medicine Physician
  • St Louis Park, MN
National Provider Identifier
1619389525
Registry record updated Jul 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
59660 Issued in MN
Practice address
3850 Park Nicollet Blvd
St Louis Park, MN 55416-2527
Phone
(952) 883-1000
NPI assigned
May 27, 2014
Last updated
Jul 16, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 16, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 59660 MN Primary

Addresses

Primary practice location

3850 Park Nicollet Blvd
St Louis Park, MN 55416-2527

Mailing address

8170 33Rd Ave S # Ms 21110Q
Bloomington, MN 55425-4516

Other practice location 1

4730 Chicago Ave
Minneapolis, MN 55407-3570
Phone (952) 967-7676

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20160613000266 MN Practitioner - Family Practice 8729378260 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2013
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Park Nicollet ClinicGroup PAC ID 7911819438, 1,778 clinicians

Practice addresses (Care Compare)

3850 Park Nicollet Blvd
St Louis Park, MN 55416-2527
Phone (952) 993-3123

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Park Nicollet Clinic Family Medicine CurrentSince Jul 1, 2016 Accepting new patients
Park Nicollet Clinic Family Medicine CurrentSince Jul 1, 2016 Accepting new patients
Group Health, Inc. CurrentSince Jun 13, 2018 Accepting new patients
Group Health, Inc. Urgent Care Current Accepting new patients
Park Nicollet Clinic Family Medicine Current Accepting new patients
Group Health, Inc. CurrentSince Jun 13, 2018 Accepting new patients

Locations

4730 Chicago Ave
Minneapolis, MN 55407
Phone (612) 313-0000

5320 Hyland Greens Dr
Minneapolis, MN 55437
Phone (952) 993-2400

8170 33rd Ave S
Minneapolis, MN 55425
Phone (952) 883-5463

8170 33rd Ave S
#21110Q
Minneapolis, MN 55425
Phone (952) 883-5375

8170 33rd Ave S
Stop 21110Q
Minneapolis, MN 55425

8600 Nicollet Ave S
Minneapolis, MN 55420
Phone (952) 887-6600

3850 Park Nicollet Blvd
St Louis Park, MN 55416
Phone (952) 883-1000

Organizations & group practices 6

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

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1401148800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1626393600000",
    "number": "1619389525",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8170 33RD AVE S # MS 21110Q",
            "city": "BLOOMINGTON",
            "state": "MN",
            "postal_code": "554254516"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3850 PARK NICOLLET BLVD",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554162527",
            "telephone_number": "952-883-1000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4730 Chicago Ave",
            "address_purpose": "LOCATION",
            "city": "Minneapolis",
            "state": "MN",
            "postal_code": "554073570",
            "country_code": "US",
            "telephone_number": "952-967-7676",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLACKBURN",
        "first_name": "MICHAEL",
        "middle_name": "ALAN",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-05-27",
        "last_updated": "2021-07-16",
        "certification_date": "2021-07-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "59660",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in St Louis Park, MN

Sources for this page

Verify at the official NPI Registry.