Healthcare Provider Details

I. General information

NPI: 1861441560
Provider Name (Legal Business Name): STEPHEN MICHAEL BLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 NW LOVEJOY ST UNIT 706
PORTLAND OR
97209-3566
US

IV. Provider business mailing address

23625 COMMERCE PARK SUITE 204
BEACHWOOD OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 503-719-6544
  • Fax: 866-898-2159
Mailing address:
  • Phone: 216-255-5743
  • Fax: 866-735-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036077134
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0036077134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: