Healthcare Provider Details

I. General information

NPI: 1790810448
Provider Name (Legal Business Name): ALFONSO A BLUM M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 ELM STREET
EAST CHICAGO IN
46312-3042
US

IV. Provider business mailing address

9660 WICKER AVENUE
ST JOHN IN
46373-9487
US

V. Phone/Fax

Practice location:
  • Phone: 219-398-9840
  • Fax: 219-398-9845
Mailing address:
  • Phone: 219-226-2203
  • Fax: 219-226-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01062815A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: