Provider Demographics
NPI:1912927138
Name:GUSIC, BLAZE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAZE
Middle Name:ROBERT
Last Name:GUSIC
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 1:30 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3957
Mailing Address - Country:US
Mailing Address - Phone:610-619-7410
Mailing Address - Fax:610-876-8483
Practice Address - Street 1:30 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013-3957
Practice Address - Country:US
Practice Address - Phone:610-619-7410
Practice Address - Fax:610-876-8483
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-062845-L208000000X
NV12628208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001684683Medicaid
PA025155Medicare ID - Type Unspecified
PAG66128Medicare UPIN