1689194631 NPI number — JULIE C BLOSSOM-HARTLEY MD

Table of content: JULIE C BLOSSOM-HARTLEY MD (NPI 1689194631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689194631 NPI number — JULIE C BLOSSOM-HARTLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOSSOM-HARTLEY
Provider First Name:
JULIE
Provider Middle Name:
C
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:
1689194631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 BREWSTER ST
Provider Second Line Business Mailing Address:
FCC A
Provider Business Mailing Address City Name:
PAWTUCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-729-2304
Provider Business Mailing Address Fax Number:
401-729-2541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 LAFAYETTE AVE SE STE 4000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-4692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-6922
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2017

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: 207Q00000X , with the licence number:  LP04116 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 4301509984 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4301509984 . This is a "STATE OF MICHIGAN MEDICAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: LP04116 . This is a "RHODE ISLAND MEDICAL LICENSE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".