Healthcare Provider Details

I. General information

NPI: 1689194631
Provider Name (Legal Business Name): JULIE C BLOSSOM-HARTLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE STE 4000
GRAND RAPIDS MI
49503-4692
US

IV. Provider business mailing address

111 BREWSTER ST FCC A
PAWTUCKET RI
02860
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6922
  • Fax:
Mailing address:
  • Phone: 401-729-2304
  • Fax: 401-729-2541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLP04116
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301509984
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: