Provider Demographics
NPI: | 1942397955 |
---|---|
Name: | BLUMBERG, SAMUEL H (PHD) |
Entity Type: | Individual |
Prefix: | |
First Name: | SAMUEL |
Middle Name: | H |
Last Name: | BLUMBERG |
Suffix: | |
Gender: | M |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2300 PENNSYLVANIA AVE |
Mailing Address - Street 2: | SUITE 4D |
Mailing Address - City: | WILMINGTON |
Mailing Address - State: | DE |
Mailing Address - Zip Code: | 19806-1392 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 302-652-7733 |
Mailing Address - Fax: | 302-652-7785 |
Practice Address - Street 1: | 2300 PENNSYLVANIA AVE |
Practice Address - Street 2: | SUITE 4D |
Practice Address - City: | WILMINGTON |
Practice Address - State: | DE |
Practice Address - Zip Code: | 19806-1392 |
Practice Address - Country: | US |
Practice Address - Phone: | 302-652-7733 |
Practice Address - Fax: | 302-652-7785 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-10-10 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
DE | B1-0000212 | 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
DE | 1000030225 | Other | DELAWARE PHYSICIANS CARE |
DE | 562511PHD | Other | BCBS OF DELAWARE |
DE | 234736 | Other | COMPSYCH |
DE | 562511PHD | Other | BCBS OF DELAWARE |