Provider Demographics
NPI:1780613364
Name:BLUM, WALTER B (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:B
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 1:409 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2555
Mailing Address - Country:US
Mailing Address - Phone:843-774-0800
Mailing Address - Fax:843-774-0499
Practice Address - Street 1:409 E MADISON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2555
Practice Address - Country:US
Practice Address - Phone:843-774-0800
Practice Address - Fax:843-774-0499
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14202208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC142027Medicaid
SC142027Medicaid