Provider Demographics
NPI:1053300962
Name:BLUM, LARRY WEBSTER (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:WEBSTER
Last Name:BLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64584
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 HOSPITAL DR STE 200
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6905
Practice Address - Country:US
Practice Address - Phone:410-553-8160
Practice Address - Fax:410-553-8159
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD372462084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD548571100Medicaid
MD165767OtherGROUP MEDICARE BWMC SURGICAL ASSOCIATES
MD548571100Medicaid
MD165767OtherGROUP MEDICARE BWMC SURGICAL ASSOCIATES
C34466Medicare UPIN