1215178637 NPI number — DR. MARLENE MOSS BLUMENTHAL PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215178637 NPI number — DR. MARLENE MOSS BLUMENTHAL PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLUMENTHAL
Provider First Name:
MARLENE
Provider Middle Name:
MOSS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215178637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21403 CHAGRIN BLVD
Provider Second Line Business Mailing Address:
#210
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-5322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-751-1007
Provider Business Mailing Address Fax Number:
216-464-5224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21403 CHAGRIN BLVD
Provider Second Line Business Practice Location Address:
#210
Provider Business Practice Location Address City Name:
BEACHWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44122-5322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-751-1007
Provider Business Practice Location Address Fax Number:
216-464-5224
Provider Enumeration Date:
03/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TS0200X , with the licence number:  SP265 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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