MEDICARE: DR. ILYA A BLOKH M.D.

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	207RH0003X	Hematology & Oncology Physician	043935	CT
2	207RH0003X	Hematology & Oncology Physician	MD430769	PA
3	207RH0003X	Hematology & Oncology Physician	228150	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1932164	OTHER	PA	HIGHMARK
2	50066305	OTHER	PA	CAPITAL BLUE CROSS

General Provider Information

NPI Number	:	1942253414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILYA A BLOKH M.D.

Provider Business Mailing Address
First Line	:	3319 KINGS HWY
Second Line	:	SUITE 1J
City	:	BROOKLYN
State	:	NY
Zip	:	11234-2638
Country	:	US
Telephone Number	:	718-676-4067
Fax Number	:	718-676-4068

Provider Business Practice Location Address
First Line	:	3319 KINGS HWY
Second Line	:	SUITE 1J
City	:	BROOKLYN
State	:	NY
Zip	:	11234-2638
Country	:	US
Telephone Number	:	718-676-4067
Fax Number	:	718-676-4068

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	08/15/2012

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