Basic Information
| Provider Information | |||||||||
| NPI: | 1861441560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUM | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555743 | ||||||||
| FaxNumber: | 8667353451 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 NW LOVEJOY ST | ||||||||
| Address2: | UNIT 706 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972093566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037196544 | ||||||||
| FaxNumber: | 8668982159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 03/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 036077134 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 0036077134 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 808256100 | 05 | ID | MEDICAID | 8529588 | 05 | WA | MEDICAID | BB4757956 | 01 | IL | DEA | OTHER | 1861441560 | 01 | TRICARE NORTH | OTHER | 402417602 | 05 | MD | MEDICAID | P00922031 | 01 | OR | RAILROAD MCR | OTHER | 1451169 | 05 | LA | MEDICAID | 235428 | 05 | AZ | MEDICAID | 036077134 | 05 | IL | MEDICAID | 2749477 | 05 | OH | MEDICAID | 00598870 | 05 | NY | MEDICAID | 402417601 | 05 | MD | MEDICAID |