Healthcare Provider Details

I. General information

NPI: 1780637140
Provider Name (Legal Business Name): MARY BLOME M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 KNICKERBOCKER RD
CRESSKILL NJ
07626-1022
US

IV. Provider business mailing address

516 KNICKERBOCKER RD
CRESSKILL NJ
07626-1022
US

V. Phone/Fax

Practice location:
  • Phone: 201-567-3898
  • Fax: 201-567-4164
Mailing address:
  • Phone: 201-567-3898
  • Fax: 201-567-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMA46793
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: