1205994415 NPI number — MARGARET L BLOM MD

Table of content: MARGARET L BLOM MD (NPI 1205994415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205994415 NPI number — MARGARET L BLOM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOM
Provider First Name:
MARGARET
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1205994415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 EASTWARD LN
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
ELLSWORTH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04605-1744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-667-5999
Provider Business Mailing Address Fax Number:
207-667-0555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
270 HIGH ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04605-1729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-667-5999
Provider Business Practice Location Address Fax Number:
207-667-0555
Provider Enumeration Date:
12/04/2006

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: 207W00000X , with the licence number:  013869 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MM5585 . This is a "MEDICARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 130420099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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