Basic Information
| Provider Information | |||||||||
| NPI: | 1083946651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLISSETT | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | SIMONE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230 | ||||||||
| Address2: | WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7186303122 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 BROADWAY | ||||||||
| Address2: | WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2010 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 25MA08706100 | NJ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 255650 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD439089 | PA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | C1-0009273 | DE | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0225169 | 05 | NJ | MEDICAID |