=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861441560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN MICHAEL BLUM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 NW LOVEJOY ST UNIT 706
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-719-6544
-----------------------------------------------------
Fax | 866-898-2159
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23625 COMMERCE PARK SUITE 204
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-255-5743
-----------------------------------------------------
Fax | 866-735-3451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | 036077134
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 0036077134
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------