Provider Demographics
NPI:1689194631
Name:BLOSSOM-HARTLEY, JULIE C (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:C
Last Name:BLOSSOM-HARTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:111 BREWSTER ST
Mailing Address - Street 2:FCC A
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-729-2304
Mailing Address - Fax:401-729-2541
Practice Address - Street 1:300 LAFAYETTE AVE SE STE 4000
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RILP04116207Q00000X
MI4301509984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301509984OtherSTATE OF MICHIGAN MEDICAL LICENSE
RILP04116OtherRHODE ISLAND MEDICAL LICENSE