Healthcare Provider Details

I. General information

NPI: 1215182662
Provider Name (Legal Business Name): KEVIN BRYCE BLUMENTHAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2008
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 CHARTER DR SUITE 130
COLUMBIA MD
21044-3128
US

IV. Provider business mailing address

25 CROSSROADS DRIVE SUITE 306
OWINGS MILLS MD
21117
US

V. Phone/Fax

Practice location:
  • Phone: 410-772-7000
  • Fax: 410-772-7072
Mailing address:
  • Phone: 443-738-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD037201
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberD0068542
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: