Provider Demographics
NPI:1881677011
Name:BLOHM, BRENDA A (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:A
Last Name:BLOHM
Suffix:
Gender:F
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:PO BOX 387
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-745-4598
Mailing Address - Fax:608-745-6242
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-745-4598
Practice Address - Fax:608-745-6242
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38801020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32383000Medicaid
G19346Medicare UPIN
WI000513135Medicare PIN