Provider Demographics
NPI:1780637140
Name:BLOME, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:BLOME
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:516 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-1022
Mailing Address - Country:US
Mailing Address - Phone:201-567-3898
Mailing Address - Fax:201-567-4164
Practice Address - Street 1:516 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-1022
Practice Address - Country:US
Practice Address - Phone:201-567-3898
Practice Address - Fax:201-567-4164
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA46793207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0915408Medicaid
NJ0915408Medicaid