Provider Demographics
NPI:1174609978
Name:BLACKMORE, CHRISTOPHER CRAIG
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:CRAIG
Last Name:BLACKMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:M4PFS
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-515-5811
Practice Address - Fax:206-515-5886
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000325352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0039587OtherLABOR AND INDUSTRIES # VM
WA8193864Medicaid
WAP00444038OtherRAILROAD MC # VM
WA5285BLOtherBLUE SHIELD # VM
WA8868697Medicare PIN
WA8868696Medicare PIN
AB12083Medicare ID - Type Unspecified
WA8193864Medicaid
WA8907283Medicare PIN