Provider Demographics
NPI:1093792517
Name:BLUMBERG, MICHAEL Z (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:Z
Last Name:BLUMBERG
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:DEPT. 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:7605 FOREST AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4938
Practice Address - Country:US
Practice Address - Phone:804-288-0055
Practice Address - Fax:804-288-2659
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028776207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1093792517Medicaid
VA00Y217A01OtherMEDICARE PTAN
VA726675OtherAETNA USHC
VA025567OtherANTHEM
VA45713OtherSENTERA
VA59480OtherSOUTHERN HEALTH
VA030001976OtherRAILROAD MEDICARE
VA006783899Medicaid
VA006783899Medicaid