1477648087 NPI number — DR. BENJAMIN DAVID BLOSSOM M.D.

Table of content: DR. BENJAMIN DAVID BLOSSOM M.D. (NPI 1477648087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477648087 NPI number — DR. BENJAMIN DAVID BLOSSOM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOSSOM
Provider First Name:
BENJAMIN
Provider Middle Name:
DAVID
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:
1477648087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
499 GLOSTER CREEK VLG STE A2
Provider Second Line Business Mailing Address:
CARDIOLOGY ASSOCIATES OF NORTH MS
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38801-4749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-620-6992
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499 GLOSTER CREEK VLG
Provider Second Line Business Practice Location Address:
SUITE A-2
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801-4600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-620-6992
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

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: 207RC0000X , with the licence number:  19111 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03670007 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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