Provider Demographics
NPI:1063677698
Name:DANIEL E BLOSSOM, P C
Entity Type:Organization
Organization Name:DANIEL E BLOSSOM, P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ERWIN
Authorized Official - Last Name:BLOSSOM
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:989-823-7076
Mailing Address - Street 1:811 W HURON AVE
Mailing Address - Street 2:
Mailing Address - City:VASSAR
Mailing Address - State:MI
Mailing Address - Zip Code:48768-1128
Mailing Address - Country:US
Mailing Address - Phone:989-823-7076
Mailing Address - Fax:989-823-3390
Practice Address - Street 1:811 W HURON AVE
Practice Address - Street 2:
Practice Address - City:VASSAR
Practice Address - State:MI
Practice Address - Zip Code:48768-1128
Practice Address - Country:US
Practice Address - Phone:989-823-7076
Practice Address - Fax:989-823-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDB004810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2809232Medicaid
MI01001582OtherHEALTH PLUS
MI950G95011OtherBCBS
MI0G95011Medicare PIN