Provider Demographics
NPI:1841637824
Name:BLAINE, SALLY ANN (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:BLAINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:ANN
Other - Last Name:CUSMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 848
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0848
Mailing Address - Country:US
Mailing Address - Phone:717-531-4094
Mailing Address - Fax:717-531-0136
Practice Address - Street 1:4520 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2910
Practice Address - Country:US
Practice Address - Phone:717-531-4094
Practice Address - Fax:717-531-0136
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4641882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology