Provider Demographics
NPI:1134188964
Name:GOLDBLUM, KENNETH D (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:GOLDBLUM
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 1:412 CREAMERY WAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2500
Mailing Address - Country:US
Mailing Address - Phone:610-384-5110
Mailing Address - Fax:610-594-2625
Practice Address - Street 1:217 REECEVILLE RD
Practice Address - Street 2:SUITE C
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-1572
Practice Address - Country:US
Practice Address - Phone:610-384-5110
Practice Address - Fax:610-594-2625
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD036863E207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001127944Medicaid
PA0192744Medicare ID - Type Unspecified
PAB40995Medicare UPIN