MEDICARE: DR. ALFONSO A BLUM M.

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	207R00000X	Internal Medicine Physician	01062815A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01062815A	OTHER	IN	PHYSICIAN LICENSE

General Provider Information

NPI Number	:	1790810448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALFONSO A BLUM M.

Provider Business Mailing Address
First Line	:	9660 WICKER AVENUE
Second Line	:
City	:	ST JOHN
State	:	IN
Zip	:	46373-9487
Country	:	US
Telephone Number	:	219-226-2203
Fax Number	:	219-226-2202

Provider Business Practice Location Address
First Line	:	4035 ELM STREET
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3042
Country	:	US
Telephone Number	:	219-398-9840
Fax Number	:	219-398-9845

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

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/13/2010

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