1720047137 NPI number — JACOB BLUM MD

Table of content: JACOB BLUM MD (NPI 1720047137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720047137 NPI number — JACOB BLUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLUM
Provider First Name:
JACOB
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1720047137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 45443
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84145-0443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-202-1032
Provider Business Mailing Address Fax Number:
904-376-4107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1888 S 14TH ST
Provider Second Line Business Practice Location Address:
CREDENTIALING DEPARTMENT
Provider Business Practice Location Address City Name:
FERNANDINA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32034-3054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-261-0922
Provider Business Practice Location Address Fax Number:
904-277-8872
Provider Enumeration Date:
03/23/2006

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: 207Q00000X , with the licence number:  28306 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME60766 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01374253 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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