Eddye Blossom II, MD
Individual provider Active NPI Obstetrics & Gynecology Physician · Monroe, LA
NPI 1003028762 · NPPES record last updated Jan 24, 2013
Key facts
- NPI
- 1003028762
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Obstetrics & Gynecology Physician 207V00000X
- License
- MD.204270 (LA)
- Practice address
- 4864 Jackson St
Monroe, LA 71202-6400 - Phone
- (318) 330-7626
- Fax
- (318) 330-7648
- NPI assigned
- May 4, 2007
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 45438 | TN | MD | Obstetrics & Gynecology Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Lake Area Physician Services LLC | Obstetrics & Gynecology | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Obstetrics & Gynecology Physician | 207V00000X | MD.204270 | LA | Yes |
| Obstetrics & Gynecology Physician | 207V00000X | 45438 | TN | |
| Obstetrics & Gynecology Physician | 207V00000X | E-6247 | AR |
Addresses
Primary practice location
4864 Jackson St
Monroe, LA 71202-6400
Mailing address
4864 Jackson St
Monroe, LA 71202-6400
Phone (318) 330-7626
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2138014 | Medicaid | LA |
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All providers in Monroe, LA · Obstetrics & Gynecology Physician in Louisiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 24, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.