Provider Demographics
NPI:1265653059
Name:BENNETT BLUM, MD INC.
Entity Type:Organization
Organization Name:BENNETT BLUM, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-750-8868
Mailing Address - Street 1:5425 E BROADWAY BLVD
Mailing Address - Street 2:PMB #358
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3704
Mailing Address - Country:US
Mailing Address - Phone:520-750-8868
Mailing Address - Fax:
Practice Address - Street 1:5150 E BROADWAY BLVD
Practice Address - Street 2:#1600
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3762
Practice Address - Country:US
Practice Address - Phone:520-750-8868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ271122084A0401X, 2084F0202X, 2084H0002X, 2084P0015X, 2084P0800X, 2084P0802X, 2084P0805X, 2084P2900X, 208D00000X, 208VP0000X, 209800000X
CAG721392084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Multi-Specialty
Not Answered2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative MedicineGroup - Multi-Specialty
Not Answered2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic MedicineGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Not Answered2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Not Answered209800000XAllopathic & Osteopathic PhysiciansLegal MedicineGroup - Multi-Specialty