MEDICARE: DR. LAWRENCE B. BLUMBERG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	ME-0030528	FL

General Provider Information

NPI Number	:	1720112238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE B. BLUMBERG MD

Provider Business Mailing Address
First Line	:	2359 TWIN BAY VW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1897
Country	:	US
Telephone Number	:	850-863-4194
Fax Number	:

Provider Business Practice Location Address
First Line	:	2359 TWIN BAY VW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1897
Country	:	US
Telephone Number	:	850-863-4194
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/08/2007

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