Provider Demographics
NPI:1053719419
Name:BARRY M. BLUMENTHAL
Entity type:Organization
Organization Name:BARRY M. BLUMENTHAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLUMENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-416-2021
Mailing Address - Street 1:1250 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:SUITE 1005
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4634
Mailing Address - Country:US
Mailing Address - Phone:954-416-2021
Mailing Address - Fax:
Practice Address - Street 1:1250 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUITE 1005
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4634
Practice Address - Country:US
Practice Address - Phone:954-416-2021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370348700Medicaid
FL370348700Medicaid