Healthcare Provider Details

I. General information

NPI: 1598829228
Provider Name (Legal Business Name): PHILIP C BLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BUFFALO WAY
JACKSON WY
83002
US

IV. Provider business mailing address

1601 E 17TH ST
IDAHO FALLS ID
83404-6313
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-8677
  • Fax:
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5933A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: