Basic Information
| Provider Information | |||||||||
| NPI: | 1285611970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUMENTAL | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 HARRISON AVE | ||||||||
| Address2: | YACC BN-C7 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145405 | ||||||||
| FaxNumber: | 6174146031 | ||||||||
| Practice Location | |||||||||
| Address1: | 49 PEARL ST | ||||||||
| Address2: | STE DOB-915 | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023012817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085801020 | ||||||||
| FaxNumber: | 5085836232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 28931 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 2077507 | 05 | MA | MEDICAID |