Provider Demographics
NPI:1700865680
Name:BLUM, JEFFREY T (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:T
Last Name:BLUM
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 1:435 SCRANTON CARBONDALE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508
Mailing Address - Country:US
Mailing Address - Phone:570-343-4334
Mailing Address - Fax:
Practice Address - Street 1:435 SCRANTON CARBONDALE HIGHWAY
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508
Practice Address - Country:US
Practice Address - Phone:570-343-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4187492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01887735Medicaid
F66287Medicare UPIN
PA01887735Medicaid