Healthcare Provider Details

I. General information

NPI: 1124060330
Provider Name (Legal Business Name): JERRY GENE BLAIVAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E 77TH ST
NEW YORK NY
10021-2318
US

IV. Provider business mailing address

445 E 77TH ST
NEW YORK NY
10021-2318
US

V. Phone/Fax

Practice location:
  • Phone: 212-772-3900
  • Fax: 212-772-1919
Mailing address:
  • Phone: 212-772-3900
  • Fax: 212-772-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number144945 1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: