Healthcare Provider Details

I. General information

NPI: 1912927138
Provider Name (Legal Business Name): BLAZE ROBERT GUSIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDICAL CENTER BLVD SUITE 205
UPLAND PA
19013-3957
US

IV. Provider business mailing address

30 MEDICAL CENTER BLVD SUITE 205
UPLAND PA
19013-3957
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-7410
  • Fax: 610-876-8483
Mailing address:
  • Phone: 610-619-7410
  • Fax: 610-876-8483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-062845-L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12628
License Number StateNV

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001684683
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: