Provider Demographics
NPI:1013032325
Name:BLUM, ANGELA SUE FORNKOHL (MD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:SUE FORNKOHL
Last Name:BLUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-0426
Mailing Address - Country:US
Mailing Address - Phone:765-521-0901
Mailing Address - Fax:765-521-9891
Practice Address - Street 1:1000 N 16TH ST
Practice Address - Street 2:SUITE G-10
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4319
Practice Address - Country:US
Practice Address - Phone:765-521-0901
Practice Address - Fax:765-521-9891
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063222A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000519955OtherANTHEM
IN200861200Medicaid