=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790891083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVE BLICBLUM, M.D.,P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 LITHIA PINECREST RD
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-6138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-681-9507
-----------------------------------------------------
Fax | 813-681-5403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 852
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33509-0852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-681-9507
-----------------------------------------------------
Fax | 813-681-5403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVE BLICBLUM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 813-681-9507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------