Healthcare Provider Details

I. General information

NPI: 1912137431
Provider Name (Legal Business Name): EMILY BLUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 GLENRIDGE DR STE 200
ATLANTA GA
30328-5579
US

IV. Provider business mailing address

1930 BRANNAN RD
MCDONOUGH GA
30253-4310
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-5206
  • Fax: 404-252-1268
Mailing address:
  • Phone: 678-284-4040
  • Fax: 678-284-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number078247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: