Healthcare Provider Details

I. General information

NPI: 1932147089
Provider Name (Legal Business Name): MICHAEL WILLIAM BLUST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 05/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST 3 SOUTH
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

PO BOX 636256
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-585-5502
  • Fax: 513-585-5511
Mailing address:
  • Phone: 513-585-5502
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35086484
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: