1700957842 NPI number — DR. SUSAN DOROTHY BLOM PH.D.

Table of content: KADIJATU KAMARA RN (NPI 1578801312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700957842 NPI number — DR. SUSAN DOROTHY BLOM PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOM
Provider First Name:
SUSAN
Provider Middle Name:
DOROTHY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1700957842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 ASHLAND ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55008-2110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-689-5250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 FOREST AVE E
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
MORA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55051-1624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-679-6346
Provider Business Practice Location Address Fax Number:
320-679-6351
Provider Enumeration Date:
11/12/2006

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: 103T00000X , with the licence number:  LP1194 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 52096BL . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 61-21928 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 72233-1010048 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114047 . This is a "U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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