Healthcare Provider Details

I. General information

NPI: 1376579318
Provider Name (Legal Business Name): ANDREW S BLUM MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 06/10/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST APC-5
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

110 ELM ST FL 1
PROVIDENCE RI
02903-4626
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-3032
  • Fax: 401-444-3205
Mailing address:
  • Phone: 401-444-3032
  • Fax: 401-444-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMD10439
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD10439
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: