MEDICARE: DR. GEORGE B BLOSSOM D.O.

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	207Q00000X	Family Medicine Physician	34001252	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	34001252	OTHER	OH	LICENSE NUMBER

General Provider Information

NPI Number	:	1275586059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE B BLOSSOM D.O.

Provider Business Mailing Address
First Line	:	3428 AMBERWOOD LN
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43617-1186
Country	:	US
Telephone Number	:	419-841-5210
Fax Number	:

Provider Business Practice Location Address
First Line	:	2526 N REYNOLDS RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-2820
Country	:	US
Telephone Number	:	419-537-1485
Fax Number	:

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/08/2007

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