Provider Demographics
NPI:1871562637
Name:BLUMENTHAL, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:BLUMENTHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1335
Mailing Address - Country:US
Mailing Address - Phone:410-415-5105
Mailing Address - Fax:
Practice Address - Street 1:1860 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-1335
Practice Address - Country:US
Practice Address - Phone:410-415-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0024242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0101480OtherEVERCARE
MD35210202OtherBCBS OF MD
9676-0004OtherCAREFIRST BCBS OF DC
093NER-352102-02OtherCAREFIRST BCBS OF MD
MD522096682001OtherTRICARE
0943ER-352102-04OtherCAREFIRST BCBS OF MD
MD008203100Medicaid
MD318541900Medicaid
T106-0038OtherBCBS-DC
093NSE-352102-02OtherCAREFIRST BCBS OF MD
093NER-352102-02OtherCAREFIRST BCBS OF MD
MD008203100Medicaid
MD590LH212Medicare PIN