MEDICARE: MS. MARY ELLEN BLONIARZ LCSW

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	1041C0700X	Clinical Social Worker	038035 LCSW-R	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7486075	OTHER		GHI#
2	IP 319133	OTHER	NY	EMPIRE BC-BS
3	133007	OTHER		CDPHP
4	77654	OTHER	NY	MVP VENDOR#
5	61745	OTHER	NY	MVP PROVIDER#
6	NE7822	OTHER	NY	EMPIREBC-BS PROVIDER ID

General Provider Information

NPI Number	:	1518026079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ELLEN BLONIARZ LCSW

Provider Business Mailing Address
First Line	:	2 TOWER PL
Second Line	:	EXECUTIVE PARK
City	:	ALBANY
State	:	NY
Zip	:	12203-3735
Country	:	US
Telephone Number	:	518-458-8639
Fax Number	:	518-458-8723

Provider Business Practice Location Address
First Line	:	2 TOWER PL
Second Line	:	EXECUTIVE PARK
City	:	ALBANY
State	:	NY
Zip	:	12203-3735
Country	:	US
Telephone Number	:	518-458-8639
Fax Number	:	518-458-8723

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

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	07/08/2007

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