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General NPI Number Information
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NPI Number | 1396514618
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Entity Type | Organization
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Legal Business Name | CM BLAINE MD PLLC
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Dates
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Enumeration Date | 12/28/2023
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Last Update Date | 12/28/2023
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Provider Practice Location Address
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Address Line | 250 PATCHOGUE YAPHANK RD STE 7
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City | EAST PATCHOGUE
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State | NY
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Zip | 11772-4862
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Country | US
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Telephone | 631-714-4402
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Fax | 631-714-4095
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Provider Business Mailing Address
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Address Line | 250 PATCHOGUE YAPHANK RD STE 7
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City | EAST PATCHOGUE
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State | NY
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Zip | 11772-4862
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Country | US
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Telephone | 631-714-4402
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Fax | 631-714-4095
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | JIYON J KIM
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Credential | PA
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Telephone | 631-714-4402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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