1659348480 NPI number — MATTHEW BLUM MD

Table of content: SARA MICHELLE HOTEN LGSW (NPI 1780411173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659348480 NPI number — MATTHEW BLUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLUM
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1659348480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2695 ROCKY MOUNTAIN AVE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80538-8702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-624-4443
Provider Business Mailing Address Fax Number:
970-490-4175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 N FOOTE AVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80909-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-365-5445
Provider Business Practice Location Address Fax Number:
719-365-5530
Provider Enumeration Date:
03/01/2006

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: 208G00000X , with the licence number:  48455 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 78658861 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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