Healthcare Provider Details

I. General information

NPI: 1407841588
Provider Name (Legal Business Name): EDWARD BLUM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 E TREMONT AVE
BRONX NY
10465-2053
US

IV. Provider business mailing address

3611 E TREMONT AVE
BRONX NY
10465-2053
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-0946
  • Fax:
Mailing address:
  • Phone: 718-822-2281
  • Fax: 718-587-8485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0067451
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: