Provider Demographics
NPI:1447649835
Name:JESSE S. GREENBLUM, MD, PA
Entity type:Organization
Organization Name:JESSE S. GREENBLUM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENBLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-261-5605
Mailing Address - Street 1:1411 S 14TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3031
Mailing Address - Country:US
Mailing Address - Phone:904-261-5605
Mailing Address - Fax:904-277-0725
Practice Address - Street 1:1411 S 14TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3031
Practice Address - Country:US
Practice Address - Phone:904-261-5605
Practice Address - Fax:904-277-0725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45241207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty