Provider Demographics
NPI:1467525303
Name:STEVE BLICBLUM M D P A
Entity Type:Organization
Organization Name:STEVE BLICBLUM M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ILLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLICBLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-685-5459
Mailing Address - Street 1:PO BOX 852
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-0852
Mailing Address - Country:US
Mailing Address - Phone:813-685-5459
Mailing Address - Fax:813-681-5403
Practice Address - Street 1:900 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2442
Practice Address - Country:US
Practice Address - Phone:863-686-1711
Practice Address - Fax:813-681-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherEMPLOYER TAX ID NUMBER