Basic Information
| Provider Information | |||||||||
| NPI: | 1326029570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUM | ||||||||
| FirstName: | ISAAC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLUM | ||||||||
| OtherFirstName: | ISAAC | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 64 GRIFFEN AVE | ||||||||
| Address2: | |||||||||
| City: | SCARSDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105837613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145745977 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 INTERVALE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104594240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9176459200 | ||||||||
| FaxNumber: | 7185897010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 10/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 111159 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 111159 | NY | N | Allopathic & Osteopathic Physicians | General Practice | 207QG0300X | 111159 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | 111159 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00696240 | 05 | NY | MEDICAID |