Provider Demographics
NPI:1215992789
Name:GOLDBLUM, SIMEON E (MD)
Entity type:Individual
Prefix:DR
First Name:SIMEON
Middle Name:E
Last Name:GOLDBLUM
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 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-706-5504
Mailing Address - Fax:410-706-5508
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-706-5504
Practice Address - Fax:410-706-5508
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD35863207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD351846-02 & 01OtherBLUE CROSS/BLUE SHIELD
DC4426930Medicaid
MD280201500Medicaid
MD351846-02 & 01OtherBLUE CROSS/BLUE SHIELD
B69488Medicare UPIN
DC4426930Medicaid