Basic Information
| Provider Information | |||||||||
| NPI: | 1912927138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSIC | ||||||||
| FirstName: | BLAZE | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190133957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106197410 | ||||||||
| FaxNumber: | 6108768483 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190133957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106197410 | ||||||||
| FaxNumber: | 6108768483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD-062845-L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 12628 | NV | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 001684683 | 05 | PA | MEDICAID |