1861441560 NPI number — STEPHEN MICHAEL BLUM MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861441560 NPI number — STEPHEN MICHAEL BLUM MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BLUM

Provider First Name:

STEPHEN

Provider Middle Name:

MICHAEL

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1861441560

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

23625 COMMERCE PARK

Provider Second Line Business Mailing Address:

SUITE 204

Provider Business Mailing Address City Name:

BEACHWOOD

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

44122

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

216-255-5743

Provider Business Mailing Address Fax Number:

866-735-3451

Provider First Line Business Practice Location Address:

1001 NW LOVEJOY ST

Provider Second Line Business Practice Location Address:

UNIT 706

Provider Business Practice Location Address City Name:

PORTLAND

Provider Business Practice Location Address State Name:

OR

Provider Business Practice Location Address Postal Code:

97209-3566

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

503-719-6544

Provider Business Practice Location Address Fax Number:

866-898-2159

Provider Enumeration Date:

05/09/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085N0700X , with the licence number:  036077134 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0202X , with the licence number: 0036077134 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 808256100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 8529588 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1861441560 . This is a "TRICARE NORTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 402417602 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: P00922031 . This is a "RAILROAD MCR" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
• Identifier: 1451169 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
• Identifier: 235428 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
• Identifier: 036077134 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 2749477 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 00598870 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
• Identifier: 402417601 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".