Healthcare Provider Details

I. General information

NPI: 1437100880
Provider Name (Legal Business Name): SAMUEL S BLUMENTHAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE DIVISION OF NEPHROLOGY
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE DIVISION OF NEPHROLOGY
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3100
  • Fax: 414-805-9059
Mailing address:
  • Phone: 414-805-3100
  • Fax: 414-805-9059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number21615
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: