Healthcare Provider Details

I. General information

NPI: 1457590366
Provider Name (Legal Business Name): KEITH S BLUM DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 12/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7730 W SAHARA AVE SUITE 109
LAS VEGAS NV
89117-2798
US

IV. Provider business mailing address

PO BOX 81136
LAS VEGAS NV
89180-1136
US

V. Phone/Fax

Practice location:
  • Phone: 702-240-4090
  • Fax:
Mailing address:
  • Phone: 702-256-3637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP781
License Number StateNV

VIII. Authorized Official

Name: KEITH BLUM
Title or Position: PHYSICIAN
Credential: MD
Phone: 702-240-4090