Provider Demographics
NPI:1437100880
Name:BLUMENTHAL, SAMUEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
Last Name:BLUMENTHAL
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF NEPHROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3100
Mailing Address - Fax:414-805-9059
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF NEPHROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3100
Practice Address - Fax:414-805-9059
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21615207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437100880Medicaid
002000162FOtherHUMANA
WI1437100880Medicaid
002000162FOtherHUMANA
WI066273601Medicare PIN