Provider Demographics
NPI:1104897339
Name:BLUMBERG, SCOTT (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BLUMBERG
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:PO BOX 4055
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-8055
Mailing Address - Country:US
Mailing Address - Phone:732-255-3911
Mailing Address - Fax:732-255-0084
Practice Address - Street 1:1749 HOOPER AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8130
Practice Address - Country:US
Practice Address - Phone:732-255-3911
Practice Address - Fax:732-255-0084
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 40974207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3369404Medicaid
NJBL520323Medicare ID - Type Unspecified
NJ3369404Medicaid