MEDICARE: MICHAEL LLOYD BLUM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	52634	KY
2	207RG0100X	Gastroenterology Physician	01083133A	IN
3	207RG0100X	Gastroenterology Physician	ME52969	FL

General Provider Information

NPI Number	:	1134115165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LLOYD BLUM M.D.

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11104 PARKVIEW CIRCLE DR STE 310
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1733
Country	:	US
Telephone Number	:	260-266-5230
Fax Number	:	260-266-5238

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	12/15/2021

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