Provider Demographics
NPI:1861441560
Name:BLUM, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
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 1:23625 COMMERCE PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-255-5743
Mailing Address - Fax:866-735-3451
Practice Address - Street 1:1001 NW LOVEJOY ST
Practice Address - Street 2:UNIT 706
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3566
Practice Address - Country:US
Practice Address - Phone:503-719-6544
Practice Address - Fax:866-898-2159
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360771342085N0700X
IL00360771342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808256100Medicaid
WA8529588Medicaid
1861441560OtherTRICARE NORTH
MD402417602Medicaid
ORP00922031OtherRAILROAD MCR
LA1451169Medicaid
AZ235428Medicaid
IL036077134Medicaid
OH2749477Medicaid
NY00598870Medicaid
MD402417601Medicaid
MD402417601Medicaid
NY00598870Medicaid
OH2749477Medicaid
ORP00922031OtherRAILROAD MCR
ILBB4757956OtherDEA
MD402417602Medicaid