Healthcare Provider Details

I. General information

NPI: 1962441501
Provider Name (Legal Business Name): MICHAEL BLUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/30/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E LOCUST ST
LONE PINE CA
93545-8044
US

IV. Provider business mailing address

8223 BIBURY LN
DUBLIN OH
43016-7354
US

V. Phone/Fax

Practice location:
  • Phone: 760-876-5501
  • Fax:
Mailing address:
  • Phone: 614-571-4313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME149711
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35045068-B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: