1255501557 NPI number — DR. DAVID B BLOSSOM M.D.

Table of content: DR. DAVID B BLOSSOM M.D. (NPI 1255501557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255501557 NPI number — DR. DAVID B BLOSSOM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOSSOM
Provider First Name:
DAVID
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1255501557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3609 PARK EAST DR
Provider Second Line Business Mailing Address:
#207
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-4331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-360-0456
Provider Business Mailing Address Fax Number:
216-360-9449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6115 POWERS BLVD
Provider Second Line Business Practice Location Address:
#205
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44129-5471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-884-2909
Provider Business Practice Location Address Fax Number:
440-884-3766
Provider Enumeration Date:
03/03/2008

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: 207RI0200X , with the licence number:  35086446 , 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)

  • Identifier: 2837943 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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