MEDICARE: BLAUM BREAST CARE SPECIALIST LLC

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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1467723866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAUM BREAST CARE SPECIALIST LLC

Provider Business Mailing Address
First Line	:	480 PIERCE ST
Second Line	:	NEW BRIDGE CENTER, SUITE #312-314
City	:	KINGSTON
State	:	PA
Zip	:	18704-5512
Country	:	US
Telephone Number	:	570-714-3911
Fax Number	:	570-714-3912

Provider Business Practice Location Address
First Line	:	480 PIERCE ST
Second Line	:	NEW BRIDGE CENTER, SUITE #312-314
City	:	KINGSTON
State	:	PA
Zip	:	18704-5512
Country	:	US
Telephone Number	:	570-714-3911
Fax Number	:	570-714-3912

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	BETH A BRENNAN
Credential	:
Telephone Number	:	570-693-6163

Provider Enumeration Date	:	01/18/2012
Last Update Date	:	01/18/2012

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