Healthcare Provider Details

I. General information

NPI: 1861457384
Provider Name (Legal Business Name): RANDALL E BLOME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

IV. Provider business mailing address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

V. Phone/Fax

Practice location:
  • Phone: 503-879-2002
  • Fax: 503-879-2015
Mailing address:
  • Phone: 503-879-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD17595
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: